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'fr 
 
 TEXT BOOK 
 
 OF 
 
 ► 
 
 MEDICAL AND SURGICAL 
 GYNECOLOGY 
 
 FOR THE USE OF STUDENTS AND 
 PRACTITIONERS 
 
 BY 
 
 R. W. Garrett, M.A., M.D., 
 
 Professor of Obstktrics and Gynecology in the Medical Faculty, 
 
 Queen's University, Kingston; Gyn-«couOgist to the 
 
 Kingston General Hospital. 
 
 CONTAiNING OVER ONE HUNDRED ILLUSTRATIONS. 
 
 KINGSTON. ONT. 
 1897. 
 

 at the Department of Agiioulture, 
 
TO 
 FIFE FOWLER, 
 
 PROFESSOR OF THK PRINCIPLES AND PRACTICE <>K MKDICINI?, AND 
 
 DEAN OF THE MEDICAL FACULTY IN QUEEN's 
 
 UNIVERSITY, KINGSTON, 
 
 THIS BOOK IS RKHPKCTFDLLY DEDICATED BY 
 
 THE AUTHOR, 
 
 IN RECOGNITION OF LIFE LONG SERVICES AS A PIONEER AND 
 STEADFAST LABORER IN THE (JAUSE OF HIGHER 
 ■'- MEDICAL EDUCATION IN CANADA. 
 
is 
 
PREFACE. 
 
 During the many years the author has been engaged 
 in teaching in various departments of medicine, it always 
 appeared that much valuable time was lost to the student, 
 and important points missed, in efforts to secure such 
 notes as would furnish him with a knowledge of the 
 teachings of the lecturer. 
 
 When it is demanded of a teacher to so arrange his 
 lectures that his listeners may secure the required notes, 
 liis efforts are apt to become dry and uninteresting, and 
 often simply a species of dictation. 
 
 In the opinion of the author, lectures, to be interesting, 
 instructive, and impressive, should assume more the form ' 
 of demonstrations, than set lectures, during which im- 
 portant features might be made plain, knotty questions 
 discussed, obscure points elucidated, and methods for 
 medical and surgical treatment made clear by the aid of 
 blackboard drawings, maps, plates, and morbid specimens, 
 leaving the intervening material for study elsewhere. 
 
 The large and excellent text books on the market are, 
 as a rule, too cumbersome to carry backwards and for- 
 wards to class, and in order that the student might have a 
 convenient text book for such a purpose, and in which he 
 might note important points dwelt upon, and in order that 
 the lecturer might feel he was free to demonstrate the 
 subject as seemed best, without being confined to set 
 lectures, it occurred to the author to place his extended 
 notes in the form of a text book of such proportions as 
 would not be cumbersome, and yet sufficiently compre- 
 hensive as to fully cover the subject. By such means it 
 is hoped to make class attendance less burdensome or 
 
PREFACE. 
 
 irksoiiK*, the material imparted more instructive, and 
 lessen the time required by students in securing an 
 accurate knowledge of the subject. 
 
 While imdertaking the task., acknowledged by the 
 author to be a difficult one, it occurred to him that by 
 extending the notes a little further the work might be- 
 come a useful adjunct to the general practitioner, whose 
 busy life prevents him securing on all occasions the time 
 necessary for consulting larger works. For such, however, 
 it is not intended as a work for extended research, but 
 from its methbd of compilation, and from its extensive 
 index, it is hoped that it will serve as a means for ready 
 reference, as well as an index to the many large and 
 excellent works on the subject. 
 
 With these objects in view, the author has endeavored 
 to place the subject in as plain and simple a manner as 
 possible, prefevring simplicity of expression to the adorn- 
 ment of Iniigup.ge. Each subdivision has been briefly 
 described, doubtful points, or subjects open to discussion, 
 discarded, raid oidy such treatment recommended as has 
 stood the test of experience, believing it better to be 
 armed with a few reliable methods of treatment than 
 surrounded by a wilderness of uncertainty. 
 
 Iti the method of arranging the various subdivisions, 
 tiio author has followed that adopted by Grarrigue in his 
 excellent work, feeling confident that regional classifica- 
 tion is simpler at least than a pathological one. 
 
 In the description of diseases, or of surgical methods 
 adopted for their relief, names of individuals have, as far 
 as possible, been avoided, as being often misleading. 
 
 While expressing his own convictions, the author has 
 endeavored to interweave into the pages of the work the 
 opinions of those who represent the most recent and 
 advanced thought, and of those who have been separated 
 out for distinction in the subjects upon which they have 
 written. 
 
PREFACE. 
 
 Mnrgiunl n^ferences mid foot notoH have been nvoid(>(l. 
 because a knowledge of the source of tlie literature that 
 has been incorporated is of no advantage to the student 
 until he has mastered tlie rudiments of the science, and 
 the practitioner can find in tho large works of reference 
 all the historical or other facts v;hich he may seek. 
 
 Acknowledgment of valuable information is due to 
 the following sources: — Diseases of Women, Cxarrigue; 
 Medicdl and Surgical GymvcokHjy, Pozzi; Diseases of 
 Women, Thomas and Munde; American Text Book of 
 (rijna'coloyij, Baldy; Clinical Gijna'colocfy, Keating and 
 Coe; A System of Medicine, Allbutt and Playfair, Vol. II; 
 Diseases of Women, Lawson Tait; Matnadof (it yna'colo(jy, 
 H. T. By ford; Manual of Gyna'colotjy, Hart and Barbour, 
 Surgical Diseases of the Ovaries and FalUrpiau Tubes, 
 Bland Sutton; Te.rt Booty of Ahdominal Surgery, Keith; 
 Ahdomiuid Surgery, Greig Smith; Diseases of Women, 
 Skene; Feuiale Felric Organs, Savage; System of Sur- 
 gery, DenniH; American Text Bool\ of Surgery; Practice 
 of Medicine, Osier; American Text Booix of Obstetrics; 
 Surgical Patfiology and Morbid Amdomy, Bowlby ; 
 Electricity in Diseases of Women, Massey ; Aseptic 
 Surgical Teclinique, Hunter Eobb; Manuid of Surgical 
 Asepsis, Carl Beck; Principles of Bacteriology, Abbott. 
 
 In conclusion, the author wishes to acknowledge his 
 indebtedness to Dr. W, T. Connell for valuable assistance 
 in the preparation of the work, and to E. J. Barker Ponse, 
 proprietor of the British Whig, for the facilities offered, 
 and the generous interest shown by him while the work 
 was passing through the press. 
 
 52 Johnston Street, 
 
 Kingston, Ontario. 
 September, 1897. 
 
CONTENTS. 
 
 PART ONE. 
 PRINCIPLES OF GYNyECOLOGY. 
 
 CHAPTER I. 
 
 PAGE. 
 
 Introduotouy y 
 
 CHAPTER II. 
 Development of the Female Genitals 12 
 
 Wolffian diictB. — Wolffian bodies. — Ovaries. -M uUeiian 
 ducts. —Falloi)ian tubes. — Uterus and vaj^ina.— Urethra. — 
 Vulva. 
 
 CHAPTER III. 
 Anatomy 16 
 
 The pelvis. — Mens > eneris. — Vulva. — Labia inajora. — 
 I^abia minora. — Clitoris. — Vestibule. — Vestibule- vaginal 
 gland'*. — Vulvovaginal glands. — Vagina. — Hymen. — 
 Uterus. — Fallopian tubes. — Ovaries.— Parovarium. — Ortran 
 of Rosenniuller. — Urethra. — Bladder. — Ureters. — Rectum. — 
 Pelvic peritoneum. — Pelvic floor. — Pelvic fascia. — Pelvic 
 diaphragm. — Perineal region. — Perineal fa&cia. — Perineal 
 muscles. — Perineal body. 
 
 CHAPTER IV. 
 
 Gyn^colooical Technique 40 
 
 Sepsis. — Septic infection. — Principal micro-organisms con- 
 cerned. — Asepsis. — Principles of sterilization. — Sterilization 
 by dry and moi&fc heat. — Fractional sterilization. — Chemical 
 disinfection. — Practical application of surgical asepsis. — 
 Methods for cleansing the hands and field of operation. — 
 Sterilization of instruments and instrument ^rays. — A.septic 
 sutures and ligatures. — Methods for sterilizing catgut. — 
 Sterilization of silk, silkworm gut, kangaroo tendon. — Steril- 
 ized dressings. — Preparation and sterilization of sponges. — 
 Aseptic drainage. — (ilass drainage tubes and gauze drains. — 
 A8e})tic irrigating fluids. — Dusting powders. — List of instru- 
 ments for operations. 
 
2 CONTENTS. 
 
 PAIJK. 
 
 CHAPTER V. 
 Etiology in (teneral 57 
 
 Causes of diseases of women. — Training and uifects of 
 education. — ^Personal habits. — Infectious diseases. 
 
 CHAPTER VI. 
 
 An.esthetics 62 
 
 Ciioir ^ of ana'sthetics. — Instructions to be observed in 
 administration.^ — Methods of administration. — Treatment of 
 dangerous symptoms during administration. 
 
 CHAPTER VII. 
 Examination in General. '. 68 
 
 (Jeneral outlines of dih'erential diagnosis. — Form for case 
 taking. — Physical examination. — Methods of e>:amination. — 
 Instrumeiiwtl examination. — Examination of interior of 
 uterus and bla(hler. — C'ystoscopy. — Examination of ureters. 
 
 CHAPTER VIII. 
 
 Gyn/Ecolooical Therapeutics 86 
 
 (jreneral liygiene. — Special gyna'cological drugs. — Local 
 therapeutics. — External and internal applications. — Medi- 
 cated pessaries, tampons, and suppositories. — Applications 
 to uterus. — Vesical injections. — ("uretting — Pelvic massage. 
 
 CHAPTER IX. 
 Post Operative Treatment 96 
 
 CHAPTER X. 
 
 Gynecological Application of Electric Currents 1(X) 
 
 Calvanic and Faradic currents. — Electrodes. — Galvano- 
 meter. — Rheostat. — Diseases in which they are applicable. 
 
 PART TWO. 
 
 FUNCTIONAL DISEASES. 
 
 CHAPTER XII. 
 
 Disorders op Menstruation 107 
 
 Amenorrhd'a. — Vicarious menstruation. — Menorrhagia and 
 metrorrhagia. — Precocious menstruation. — -Dysmenorrhd'a, 
 neuralgic, congestive, obstructive, membranous, ovarian. 
 
 CHAPTER XIII. 
 Sterility. — Nymphomania. — Leucorrhcea 127 
 
CONTENTS. 
 
 PART THREE. 
 DISEASES OF SPECIAL REGIONS. 
 
 CHAPTER XIV. 
 
 Diseases of the Vulva "j^^^ 
 
 Malformations. — Hypogpadias.— EpLspadias. — Heinaph- 
 rodism.- Hernia.— Hematocele.- Lijui ies. — Phlegmonous 
 inflammation. —Cysts and absces.ses of the vulvo- vaginal 
 glands.— Tumors— Vulvitis, simple, puruleat, follicular.— 
 
 Eruptive diseases.-Pruritus.— Hypera^sthesia.— Kraurosis. 
 — Coccygodynia. 
 
 CHAPTER XV. 
 
 Lesions op the Pelvic Floor 152 
 
 Causes of lo.ss of tonicity.— Prolapse of vagina.— Cystoc'ele 
 -Rectocele. -Anterior colporrhaphy.- Posterior colpor" 
 rhaphy.— Perineorrhaphy.— Colpo-perineorrhaphy.— Tait's 
 Hegar's and Emmet's methods of perineorrhaphy. ' ' 
 
 CHAPTER XVI. 
 
 Diseases of the Vagina ...... 171 
 
 Malformations of the hymen. - Malformations of "the 
 vaguia. -Atresia and stenosis. -Vaginitis.-Neoplasms. 
 
 CHAPTER XVII. 
 
 Genital Fistula. .^. 
 
 Urinary tistuhe, vesico- vaginal, urethro-vaginal,' vesJcV- • 
 uterme, vesico- utero- vaginal, uretero- vaginal, uretero- • 
 uterme.— Fecal fistula. 
 
 CHAPTER XVIII. 
 
 Diseases of the Urethra and Bladder. . . 194 
 
 Malformations of the urethra. -Malformatmns of the 
 
 bladde..^ -Irritable urethra.-Urethritis.-(Jranular erosion 
 
 o urethra.-Stricture of urethra. -Urethrocele. -Irritable 
 
 Wadder.-Cystitis.- Vesical calculi. - Foreign bodies.- 
 
 : . JVeoplasms.— Ureters. 
 
 CHAPTER XIX. 
 
 Diseased of the Uterus 
 
 Malformations. -Uterus unicornis.- Uterus bi'coi 
 Uterus duplex. -Uterus septus. -Atresia uteri. 
 
 207 
 
 nis.- 
 
4 CONTENTS. 
 
 PACiE. 
 
 CHAPTER XX. 
 Diseases of the Uterus, Continued 218 
 
 Laceration of the cervix. — Trachelorrlmpliy. 
 
 CHAPTER XXI. 
 
 Diseases of the Uterus, Continued 219 
 
 Metritis. — ^Acute endometritis. — Acute metritis. — Endo- 
 cervieitis. — Chronic corporeal endometriti.s. — Chronic me- 
 tritis. 
 
 CHAPTER XXII. 
 Diseases of the Uterus, Continued 239 
 
 Accjuired atresia. — Stenosis of the cervix. — Hypertrophy. 
 — Supra- vaginal amputation of cervix. 
 
 CHAPTER XXIII. 
 Diseases of the Uterus, Continued 241 
 
 Disphicements. — Anteversion. — Anteflexion. — Retroversion 
 and retroflexion. — Pessaries. — Extra-peritoneal shortening of 
 the round ligaments. — Alexanders operation. — Intra- ()eri- 
 toneal shortening of the round ligaments. — Vaginal hystero- 
 jiexy.— Abdominal hysteropexy. — Latero-versions and lat- 
 ero-ttexions. — Prolapsus. — Inversion. 
 
 CHAPTER XXIV. 
 Diseases of the Uterus, Continued 261 
 
 Benign neoplasms. — Myxoma, glandular polypus. — Fibro- 
 mata. — Myomectomy. — C<i4iotomy. — Abdominal hysterec- 
 tomy. 
 
 CHAPTER XXV. 
 
 Diseases of the Uterus, Continued 276 
 
 Malignant neoplasms. — Cancer of the uterus. — Cancer of 
 the cervix. — Vaginal hysterectomy. — Cancer of the corpus 
 uteri. — Sarcoma. 
 
 CHAPTER XXVI. 
 
 Diseases of the Fallopian Tubes 292 
 
 Malformations. — Salpingiti.s. — Acute catarriial and puru- 
 lent salpingitis. — Interstitial salpingitis. — Abdominal aal- 
 pingo-oophorectomy. — Vaginal salpingo-oophorectomy. — 
 Pyosalpinx. — Hydrosalpinx. — Ha-matosalpinx. — Atrophy of 
 the tube. 
 
 CHAPTER XXVII. 
 Pelvic Inflammation 309 
 
 Pelvic cellulitis.— Pelvic abscess. — Pelvic peritonitis. 
 
CONTENTS. 5 
 
 CHAPTER XXVIII. 
 
 Diseases of the Ovaries 320 
 
 xMalfoinmfcions.— Displacements.— ProIapHe of the ovary.— 
 Hernia of the ovary.— Hypera-mia and haanatoma.— Acute 
 oophoritis. 
 
 CHAPTER XXIX. 
 
 Diseases of the Ovaries, Continued 330 
 
 ^ C'hronicoophoricis.—Neopksms.— Cysts of the ovaries. - 
 Small residual cysts. -Follicular cysts.— Cysts of the corpus 
 luteum.— Tubo-ovarian cysts.- Proliferatingglandular cysts. 
 —Proliferating papillary cysts. — Dermoid cysts. —Broad 
 ligament cysts. —Ovariotomy.— Solid tumors. 
 
 CHAPTER XXX. 
 
 Ectopic Gestation ^ qkc 
 
 Classification. -Tubal pregnancy.— Abdominal pregnancy. 
 
 CHAPTER XXXI. 
 Pelvic Hematocele and Pelvic Hematoma ..... 365 
 
 CHAPTER XXXII. 
 Genital Tuberculosis 3-^2 
 
 CHAPTER XXXIII. 
 
 Tuberculosis of the Peritoneum 377 
 
 PART FOUR. 
 DISEASES OF THE FEMALE BREAST. 
 
 ^ CHAPTER XXXIV. 
 
 Anatomy.-The Nipples.-Neuroses.-Mastitis - 
 
 Mammary Abscess.— Cysts 332 
 
 ., ; CHAPTER XXXV 
 
 Neoplasms ^^^ 
 
 Cla8sification.-Adenoma.-Fibro-adenoma.-Cvstic adj 
 noma.-Papilkry cysts. -Sarcoma. -Adeno-sarc^ma. -Car- 
 : " c.noma.-Scirrhus.-Encephaloid carcinoma. -Colloid car- 
 cmoma. 
 
LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE. 
 
 1. Mullei'.s ducts l4 
 
 2. Coale.scence of ducts 14 
 
 3. Disappearance of septum 15 
 
 4. Ap{)earance of fundus and cervix 15 
 
 5. Virginal vulva 17 
 
 6. Shape and relative length of vaginal walls 19 
 
 7. Horizontal section in inferior strait of pelvis 19 
 
 8. Varieties of hymen 20 
 
 9. Virgin uterus 22 
 
 10. Muscular layers of uterus 23 
 
 1 1. Sagittal section of female pelvis 24 
 
 12. Blood vessels of the pelvis 26 
 
 13. Blood vessels of uterus and vagina 27 
 
 14. View of uterine appendages .... 28 
 
 15. Relations of ureters and uterine arteries to cervix 33 
 
 16. Muscles of perineum and pelvic floor 39 
 
 17. Shape of perineal body 40 
 
 18. Higbei -^ bivalve speculum 79 
 
 19. Sims' nculum 79 
 
 20. Simpsof "^ound 80 
 
 21. Bozeman .-- . essing forceps 81 
 
 22. Vulsellum forceps 81 
 
 23. Hanks' dilators 82 
 
 24. Goodell's dilators 82 
 
 25. Skene's endoscope 83 
 
 26. Skene's endoscope 83 
 
 27. Skene's endoscope 83 
 
 28. Double urethral dilator 84 
 
 29. Kelly's cystoscope . . 84 
 
 30. Kelly's obturator 84 
 
 31. Cystoscopic examination of the bladder 85 
 
 32. Burrage's cervical speculum 93 
 
 33. Intrauterine douche 93 
 
 34. Tenacula 94 
 
 35. Wire loop curettes 94 
 
 36. Sharp curette 94 
 
 37. Martin's cutivneous electrode 101 
 
 38. Bipolar electrodes 103 
 
LIST OF ILLUSTRATIONS, i 
 
 FIG. PA,~.E. 
 
 SO. Dysmenorrhieal membrane 1'23 
 
 40. P olliciilar vulvitis 145 
 
 41. Cystocele and rectocele 155 
 
 42. Clover'.s crut'-h 158 
 
 43. Stoltz's operation for cystocele and Hegar'-i operation for rectocele 159 
 
 44. Operation for incomplete laceration of perineum Itil 
 
 45. Operation for laceration of the perineain and sphincter ani 162 
 
 46. Complete laceration of perineum extending into recto-vaginal 
 
 septum 164 
 
 47. Diagram of o})eration for simple rupture of perineum 165 
 
 48. Diagram of oj)eration for complete rupture of perineum 165 
 
 49. Tail's flaj) splitting operation for incomplete rupture of perineum 166 
 
 50. Tait's Hap splitting operation for eom[)lete rupture of perineum. 166 
 
 51. Flap splitting operation -appearance of wound and introduction 
 
 of sutures 167 
 
 52. Hegar's colpo-perineorrhaphy 168 
 
 53. Hegar's operation for complete laceration of the perineum 16') 
 
 54. Emmet's denudation in colpo-perineorrhaphy 170 
 
 55. Emmet's colpo-perineorrhaphy —sutures partially inserted 170 
 
 56. Atresia of the vaginal outlet 172 
 
 57. Double vagina 174 
 
 58. Operation for vesico-vaginal fistula 187 
 
 59. Des^elopment of the genito-urinary tract in the female 208 
 
 60. Uterus unicornis 209 
 
 61. Didelphic uterus and divided vagina 209 
 
 62. Uterus duplex . . 210 
 
 63. Two-cliambered uterus 210 
 
 64. Atresia of the cervix uteri 211 
 
 65. Unilateral laceration of the cervix 213 
 
 66. Bilateral laceration of the cervix, with eversion 214 
 
 67. Multiple stellate laceration of cervix 215 
 
 68. Edebohl's speculum 217 
 
 69. Lacerated cervix — surface denuded and sutures passed 218 
 
 70. Lacerated cervix with sutures tied 218 
 
 71. Erosion of the cervix 226 
 
 72. Amputation of cervix 238 
 
 73. (iehrung's pessary 243 
 
 74. Anteflexion of uterus with retropo'jition ... 247 
 
 75. Hodge pessary 250 
 
 76. Albert Smitli })e.ssary 2i';0 
 
 77. Thomas retroflexion pessary . 250 
 
 78. Procidentia uteri .... 254 
 
 79. Incomplete inversion of uterus 258 
 
8 LIST OF ILLUSTRATIONS. 
 
 FIC. PA(iF. 
 
 80. (Complete inversion of uterus 2.')8 
 
 81. I'olypus Mimulating complete inversion of uterus 2.58 
 
 82. Fibrous polypus of uterus 2.59 
 
 8.3. Interstitial fibroids of uterus 262 
 
 84. Subserous and submucous fibroids 262 
 
 85. Pedunculateu fibroid of uterus 263 
 
 86. Fibro-cysHc tumor of uterup 264 
 
 87. Application of litfntures in hysterecto.ay 274 
 
 88. Cylindrical epitiieliomn of the cervix uteri 278 
 
 89. Epithelioma of cervix uteri, vagina and bladder 279 
 
 90. Vaginal hysterectomy with ligature 283 
 
 91. Vaginal hj'sterectomy with clamps 285 
 
 92. Medullary cancer of body of uterus 288 
 
 93. Salpingitis with pelvic peritonitis and adhesions 295 
 
 94. Pyosalpinx and ovarian abscess 306 
 
 95. Ovary with dropsical follicles 328 
 
 96. Diagram of structures in and adjacent to the broad ligament. . 332 
 
 97. Small multilocular cyst 3.34 
 
 98. Microscopic examination of fluid from ovarian tumors 335 
 
 99. Papillomatous ovarian cyst 3.36 
 
 100. Dermoid cyst, showing plates of bone and long tawny hair. . . . 338 
 
 101. Unilocular cyst .340 
 
 102. Diagnosis of ascites from ovarian tumor 346 
 
 103. Ligature of pedicle in three sections 351 
 
 104. Staffordshire knot ... 352 
 
 105. Spindle-celled sarcoma of ovary. . . 355 
 
 106. Retro-uterine hannatocele 366 
 
 107. Primary tuberculosis of the tube.s and ovaries 373 
 
 lOS. Fibroadenoma of the breast 391 
 
 109. Proliferous cyst-adenoma. . 392 
 
 110. Section of a breast with scirrhus carcinoma 395 
 
 111. Scirrhus carcinoma of the breast 396 
 
Medical and Surgical Gynaecology. 
 
 PART ONE. 
 
 PRINCIPLES OF GYNAECOLOGY. 
 
 CHAPTER I. 
 
 INTRODUCTORY. 
 
 The term Gynaecology is understood to designate the 
 afPections of the genital organs in the i ^male sex otlier 
 than those immediately connected with pregnancy, child- 
 birth, and the puerperal state, but clinically it is difficult 
 to disassociate the one from the other, as the accidents 
 and diseases arising diiring that critical period are the 
 most fruitful sources of diseases peculiar to women. 
 
 Great progress has been made in every domain of 
 medicine. Every branch of it has felt the new impulse, 
 but in no department has it been so marked as in this one. 
 
 In tracing the development of modern gynaecology it 
 is difficult to keep pace with, or even estimate the rapid 
 l^rogress it has made. Twenty years ago it was a mere 
 appendage to obstetrics, the teaching of it being limited 
 to a few lectures at the end of the session ; to-day it is one 
 of the most honored chairs in every medical curriculum. 
 The teachings and practice of to-day bring hope and 
 comfort to many a home which in days gone by would 
 have been the possessor of a wife or mother or daughter 
 doomed to hopeless invalidism under the label of " weak 
 spine," "spinal irritation," "chronic ovaritis," "cellulitis," 
 " irritable womb," and the like. 
 
10 MEDICAL AND SURGICAL GYNyECOLOGY. 
 
 Tlin/U^h itH advnncoK tlioro hns been given to suigery 
 the oj)erfvtion for the removal of pelvic tumors, nnd to-day 
 ovarian cysts are removed wiHi a mortality far below any 
 other cajntal operation. The ingenioxis position of Tren- 
 delenber!.? has rendered easy the total extirpation of uterine 
 fibroids: the patiiology and op(>rative treatment of extra- 
 uterine jjregnancy to-day snatches women from what then 
 would have been considerotl the very jaws of death. 
 
 Vesioo-vaginal and recto-vaginal listuhe yield readily 
 to operation and permanent relief can with almost certainty 
 be promised. Uterine cancer, the presences of which until 
 very recently signed the death-warrant of the sufferer, is 
 now treated with such good results as to far surpass the 
 most sanginne expectations, offering at least an increased 
 term of life and sometimes the total eradication of the 
 disease. Chronic endometritis, once so intractable, now 
 readily yields to the use of the curette. 
 
 To gyniecology is due many of the advances in general 
 surgery. From it has sprung the scientitic trentment of 
 appendicitis, the surgery of the kidneys and gall-bladder, 
 as well as that of all intestinal and visceral lesions. 
 
 While recounting the triumphs recorded, it must 
 always be a pleasant task to acknowledge the deejj debt of 
 gratitude which gynecology owes to Sir Joseph Lister, 
 for without his scientitic discoveries and brilliant teaching, 
 the successes of modern pelvic and abdominal surgery 
 could never have been won, and the announcement made 
 that he has been raised to the peerage, has been received 
 with the most lively feeling of satisfaction throughout the 
 medical profession, which is proud to recognise him 
 among its members and on which he has already shed so 
 much lustre. 
 
 While recognising that pregnancy and child-birth are 
 fruitful sources of diseases in women, it is not by any 
 means the greatest source. It is, therefore, the duty of 
 every student of the subject not to be content with a 
 
INTRODUOTORy. 11 
 
 '.:uowl(Hlgu of the aotunl existence of diHense, but to study 
 out the etioloj^icnl fnctors nnd the methods by which they 
 mny be nmeiiorated, li^ssened, or prevented. 
 
 A hir^e factor m.iv be found in faulty echication. Tlie 
 chief strain of reproducing falls np'jn woman. She bears 
 the burden of gestation, parturition, lactation, and of 
 maternity, and for this great end she needs the most 
 perfect physical development. The growth and well-being 
 of her body should, therefore, be as carefully looked after 
 as the growth and well-being of her mind, a concorddt in 
 female education not sufficiently maintained. During 
 girlhood days too much time is spent in the school- 
 room, or in poring over books at home, when she 
 should be at play. Just as womanhood is asserting 
 itself, come the competitive examinations, which select 
 the brightest and most intellectual, and who are often 
 the most delicately constructed, for i)romotion to the high 
 schools and universities. Two to four or even five years, 
 most precious years for them, years needful for the perfect 
 development of not oidy their general health but for the 
 development of the reproductive organs and for the 
 establishment of their functions, are spent in antagonism 
 between brain growth and body growth. Possibly after 
 leaving school, the worn out, rest-needing girl launches 
 into the married state, and this young girl, wilting under 
 the double strain of wifehood and motlierhood, remains 
 ever after an invalid with her uterine and ovarian diseases, 
 or with nerve prostration and its jjrotean mimicry of 
 uterine symj)toms. 
 
 Undoubtedly some of the worst forms of disease arise 
 from specific infection by husbands, giving rise to sterility, 
 miscarriage, oophoritis and salpingitis of every kind and 
 degree, pelvic and intestinal adhesions, chronic ill-health, 
 and even death. 
 
 Probably the most common of all causes is the pre- 
 vention of conception. By the methods adopted so much 
 
12 MEDUAL AND SURtHCAL (lYN. ECOLOGY. 
 
 en^orj^tMiiiMit and hy[)('ri)lnHifi and diHor^niiization of the 
 uterine HtructurcH and appendages are apt to take plairo, 
 that their hi^alth breaks down and they bee.onie (H)iupara- 
 tive invalids. It is well to remembc^r, when consitU^rin^^ 
 such important factors, that history does not forget to 
 repeat itself. In the time of Julius Cjesar, celibacy and 
 childlessness became more and more common; criminal 
 abortion was frequently practisc^d; pregnancy was con- 
 sidered a mar to beauty, and the Roman empire, for the 
 want of tncn, was overrun by northein hordes. Greece, 
 once the pride of the world, at last (juailed before the 
 Roman Eagle and became a vassal because she could not 
 brook to have her classic tastes interrupted by family 
 cares and family ties. 
 
 It cannot but be recognised that those who are the 
 guardians of the public health are the guardians of the 
 nation's prosperity and greatness, and this is doubly true 
 in the case of the health of women who are to become the 
 mothers of our future men, for unless their health and 
 strength and well-being are preserved, the brain and bone 
 and sinc^w of the country will, by progressive decadence, 
 dwindle towards extinction. 
 
 CHAPTER II. 
 
 DEVELOPMENT OF THE FEMALE GENITALS. 
 
 For a proper understanding of the malformations and 
 diseases of the female genitals, it is necessary to be able 
 to trace the various steps in their development. 
 
 The ^Volffian Ducts are the first organs belonging to 
 the genital sphere to api)ear. There is one on either side 
 of the body and is situated between the proto-vertebral 
 column and the lateral plates. Originally it is a solid 
 cylindrical cell mass, but later becomes tunnelled. The 
 upper end connects with the WolflSan body, the lower end 
 
DEVELOPMENT OF THE FEMALE GENITALS. 13 
 
 opens into tlmt pnrt of tiio nllantoiH situatt'd in tlu^ body 
 of tho embryo nnd communicfttoH with the cloacn. In the 
 female the Wolffian duct dinappearH mon^ or Ichh vom- 
 ph^ti^ly, remnantH only of it beinj^ found in the broad 
 ligannuits. 
 
 The Wolffian Bodies are two long prismatic bodies, 
 one on either side of tlu^ median line, nnd appear shortly 
 after the Wolffian ducts. The lower end is fasttnied to 
 tlu^ inguinal region by a liganuMit, which in course of 
 time becoini^s the round ligament of thci uterus. These 
 bodies originate from the mesothelial lining of tlu^ body 
 cavity, and form at first a row of pear-shaped bodies. 
 Lat(T they separate from it, acquire n lumen and form a 
 row of vesicles, each of which soon connects with the 
 Wolffian du(!t by absorption of the tissue betwecui their 
 cavities and the bore of the duct. In the femah^ the 
 Wolffian body is transformed into Jiost'tiviullcr's oiujdii or 
 the pdroniriintt and stray tubes found between the 
 parovarium and the uterus. 
 
 The Ovaries. The sexual glands are situated on the 
 inner side of the Wolffian body, to which they are fastened 
 by a fold of peritoneum, the nicsordnKiii. The k)wer end 
 is fastened to the Wolffian duct by a ligament which later 
 beconuis the li<j(ini<'td of tlw ovarij. The blood vessels 
 enter originally at the upper end of the mesovarium 
 enclosed in a fold of peritoneum, which in time becomes 
 the iiifundibnlu-ju'lvic ligament. To the outer side of the 
 mesovarium is attached the mrsosdlpinx or mcsciitrrij of 
 the tube which later is calh^d the ((l(( vcsju'i'filioni's (bat's 
 wing), and contains the remnants of the Wolffian body, 
 particularly the parovarium. The ovaries are also subject 
 to descent. At birth they are above the ilio-pectineal 
 line, and descend into the pelvis during the first two 
 or three months of extra-uterine life. 
 
 The Mullerian Ducts appear soon after the Wolffian 
 body as an extended ridge of thickened mesothelium along 
 
14 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 tho outer Hide of tlio upper (muI of the Wolffifui body. The 
 lower part is nt first formed by n solid eolumii of cells 
 v" ioh Inter becomi^s tuniu41ed so ns to form n tube. They 
 form in the female the Fidlopiiiii tubes, ulie uterus, and 
 vagina. 
 
 Fi<;. I. — Mui.i.kk's nucrs. Kk;. 2.— C(iai.f.scknck of Ducts. 
 
 The Fallopian Tubes are formed of that part of tin? 
 Mullerian ducts which lies above tho round ligament of 
 tho Wolffian body. The cells of tho wall form the fibrous 
 muscular and mucous coats of tho fully developed tube, 
 and fringes forming the jimbriiv grow out around tho 
 abdominal op(^niiig. 
 
 Uterus and Vagina. The part of tho Mullerian ducts 
 b(4ow the round ligament, together 'with the lower end of 
 the Wolffian ducts, forms a quadrangular cord called the 
 (jcniUd cord. The walls between tho Mullerian ducts are 
 absorbed and thus but one canal is formed. The genital 
 cord is further developed so as to form the uterus above 
 and tho vagina below. While the fusion of the Mullerian 
 ducts is incomplete they are separated above, forming tho 
 two cornud of the uterus, but lator form but one sac with- 
 out horns. The Mullerian ducts open into the lower part 
 of the nrachus — that part of tho allantois which is 
 included in the body — and later forms the bladder. This 
 lower part, situated below the openings of tho Mullerian 
 and Wolffian ducts is called tho iiro-f/cnifdl sinus. Orig- 
 inally this sinus opens into the cloacd, but later the 
 septum is formed, dividing the cloaca and thereby separ- 
 ating the uro-genital sinus from the rectum and the uro- 
 genital opening from the anus, thus forming the perineum. 
 
DEVELOPMENT OF THE FEMALE OENITAL8. 
 
 16 
 
 The Urethra in (liftVn>iitinti'(l an a Hpocial organ from 
 the bladder, with which it hcrotoforo formed one .sac ealU«d 
 tht* urachuH. Tlio uro-gonital HinuH wiiieii Hoomod to be 
 the continuation of tho bladch^r, now appi^irH as tho 
 continuation of thi^ vaj^ina antl forniH the n'sflhiilr. Tho 
 vagina is next separated from the uteruH by the formation 
 of a ring and about the name time tlie cervix is being 
 
 Fig. 3.— Disappearance nr Septum. 
 
 4.— Appearance oi-- Kunuus and Cekvix. 
 
 diHtinguislied from the body of tlie uterus. Tlie vagina 
 becomes mucli wi(U^r, its rolimins and rn(/(i' make their 
 appearance, and later the lii/mcn is formed by ;. develop- 
 ment of the posterior wall of the vagina. 
 
 The Vulva. Originally the uro-geuital and digestive 
 tracts open into one common cavity, the clo(U'<i. The 
 cloaca opens on the surface of the body by n slit calU^l tho 
 cloacnl opening. In front of this opening app.ears an 
 elevation called the (fcnitdl iuhn'vlc, surrounded by two 
 folds calked the f/cniffd folds. A groove is formed on the 
 lower surface of the genital tubercle, called the (/cnitdl 
 fur'vow. The genital tubercle becomes tho clitoris; the 
 genital folds, the l((l)i((. majora; the edges of the genital 
 fold, the l((hia minora, a fold of which surrounds tho 
 clitoris forming the prepuce. The separation between tin 
 uro-genital sinus and the rectum is completed; the genital 
 folds grow together at their posterior end and unite 
 with the partition or septum between tho uro-genital 
 sinus and the rectum to form the perineum. 
 
16 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 CHAPTER III. 
 
 ■ * 
 
 ANATOMY. 
 THE PELVIS. 
 
 Four bones, two ossa hmnmincifa, the sacrum, and 
 the coccyx take part in the formation of the pelvis. The 
 pieces comprising the innominate bone — the ilium, 
 iscltiiini, nnd pubis — in early life are distinct, but later are 
 fused into one. The space included within these bony 
 walls is divided into two parts, the part above the ilio- 
 pectineal line is called the false pelvis, and that part 
 below, the true pelvis. The true pelvis is a short curved 
 canal, whose superior strait, inlet or hrini is bounded 
 behind by the promontory of the sacrum, laterally by the 
 ilio-pectineal lines, and in front by the ujjper margin of 
 the pubis. The inferior strait or outlet is bounded behind 
 by the tip of the coccyx, laterally by the tuber-ischii, and 
 in front by the lower border of the pubic bones. 
 
 The plane of the inlet, when the body is in an erect 
 position, forms with the horizontal an angle of about 
 forty-five degrees. The aju's of the inlet if directed up- 
 ward would pass through the umbilicus, and if prolonged 
 downward would touch the tip of the coccyx. 7Vie axis 
 of the outlet if extended upward would meet the prom- 
 ontory of the sacrum. The bones are united with one 
 another by four articulations, one in front between the 
 two pubic bones, the synij)htjsis pubis; two laterally 
 between the lateral surface of the sacrum and ilium, the 
 sacro-iliac; and cue behind between the sacrum and 
 coccyx, the sacro-coccy</eal. In addition to the ligaments 
 which bind these bones together, there are two important 
 ones closely associated with the boundary of the true 
 pelvis— the (jreater and lesser sacro-sciatic ligaments. 
 
ANATOMY. 
 
 IT 
 
 THE FEMALE ORGANS OF GENERATION. 
 
 The Genital Organs are divided into two groups: the 
 external to which belong the mans veneris, the vulva and 
 the vagina; and the internal to which belong the uterus, 
 the Fallopian luhes, and the ovaries. 
 
 The Mons Veneris lies in 
 front of the pubic bones just 
 below the hypogastric region. 
 It is composed of stout integu- 
 ment, abiindniitly suj^pliod 
 with crisp hair and a thick 
 cushion of subcutaneous adi- 
 pose and areolar tissue. The 
 liair is limited above and does 
 not extend to the umbilicus as 
 i'.i man. 
 
 The Vulva forms and sur- 
 rounds the entrance to the 
 genital canal. It is made up 
 of the labia niajora, with the 
 fonrehetfe; the labia minora 
 with the clitoris ; the vestibule 
 with the bulbs ; the fossa 
 
 Fig. 5. — Virginal Vulva : i, la!>ia majora ; • j • 1 ii T 
 
 2, fourcheite; 3. lal.ia.ninora;4,Slans naVICUlariS; aud the VUlVO- 
 ciiloridis ; 5, meatus iirinarius ; 6, vesli- "77 I 
 
 luile; 7, entrance to the vagina; 8, Vaf/in((t (fKUiaS. 
 hymen ; 9, orifice of H.irtholin's ghmcl ; 
 
 10, ant. rior commissure of labia majora ; The Labia MajOra afC tWO 
 
 11, anu ; 12, blind recess; 13, fossa •* 
 
 navicularis; 14, body of clitoris. COUSpicUOUS loUgitudiual folds 
 
 of integument Dne on either side of the median line, 
 extending from the mons veneris to within about an inch 
 in front of the anus. The outer surface; is covered with 
 pigmented epidermis and scattered hairs; the inner sur- 
 face is smooth, rose-coloured, more delicate in texture, and 
 where least exposed partakes of the character of a mucous 
 membrane. The point at which they unite in front is 
 called the anterior commissure, and behind the posterior 
 
18 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 commissitrc. Immedintely within the posterior commis- 
 sure, a cresceutic fold extends trnnsversely, the fourchcttc. 
 The space between the fonrcliette and the posterior com- 
 missure is the fossd ii(iriciil((ri)^. Each labium includes 
 A'ithin it areolar tissue, uustriped muscle fibre, and con- 
 siderable fat, and together are the homologues of the 
 scrotum in the male. 
 
 The Labia Minora or Nymphae are two thin diverging 
 folds of delicatt^ skin on the inner side of the labia majora. 
 Just before meeting in front, each divides into two leaf- 
 lets, the outer or upjier leaflet of each pasting over the 
 clitoris to unite and form the prepuce; the inner or lower 
 leaflet passing beneath to form the frciuun. They extend 
 back to about half way between the clitoris and the 
 posterior commissure, gradually merging into the sides of 
 the vaginal orifice. 
 
 The Clitoris is a small cylindrical body about an ip.oh 
 long situated in the median line below the anterior com- 
 missure. It is composed of the (/kins, a pointed tubercle 
 which forms the end and is the only part visible, and the 
 bodij which consists of two distinct corpovd cavernosa 
 attached to the symphysis by the suspensory ligament and 
 by their crura to the rami of the pubes. It is supplied 
 with erectile and muscular tissue, in diminutive similar to 
 that of the male, and has a prepuce and frenum formed by 
 the labia minora. The blood supply comes from the 
 internal pudic, the same as in the male, and the lymplKdics 
 empty into the inguinal glands. 
 
 The Vestibule includes the triangular space between 
 the clitoris, the labia minora, and the entrance to the 
 vagina. Its smooth mucous surface is broken in the mid- 
 lino about one inch behind the clitoris, by the urethral 
 opening or mecdus urinarius. 
 
 The Vestibule- vaginal Bulbs are two leech -shaped 
 organs, one on either side of the vestibule and together 
 are equivalent to the bulb in the male urethra. 
 
ANATOMY. 
 
 19 
 
 Fig. 
 
 -S..ape and relative length of 
 vaginal walls. 
 
 The Vulvo-vaginal or Bartholin's Glands nro two 
 
 small round or ovnl bodies situated on either side of 
 
 the entrance to the vagina at the posterior end of the 
 
 vestibulo - vaginal bulbs_ 
 They are r a c e ni o s e 
 glandsjSecreting a mucous 
 fluid. 
 
 The Vagina is a mus- 
 culo-membranous canal 
 lying chiefly within the 
 cavity of the pelvis and 
 exttuuling between the 
 vulva and the uterus. It 
 pierces the pelvic floor at 
 its lower end and is in 
 relation with the blad- 
 
 d«^r and urethra in front and with the rectum behind. 
 
 The (uis while corresponding in general with that of 
 
 the pelvic cavity, presents a 
 
 double or S-like curvature. 
 
 When not distended it is fold- 
 ed, the anterior and posterior 
 
 walls being in contact so that 
 
 in cross section it resembles in 
 
 shape the letter "H." When 
 
 distended it is in the form of a 
 
 truncated cone, the apex at the 
 
 vulva. The lower end dips into 
 
 the vulva by a circular opening 
 
 surrounded by the consfrietor 
 
 Vdjfina' muscle. The upper 
 
 end forms a cup to receive the 
 
 vaginal portion of the uterus, 
 
 and in its adaptation to the 
 
 parts forms a shallow pouch in •^■fcr"X'inL:;i;"'s;;:!i;'of^!: 
 
 front and behind, the autrrior ^^In^Tr:^^^^^^:^ J^' 
 
20 
 
 MEDICAL AND SURGICAL GYN^COI.OGY. 
 
 niul ])osferi()r forniccs. In the adult virgin the anterior 
 wall is about two and a half inches long and the posterior 
 about three and a half inches, but after child-birth these 
 dimensions are increased. 
 
 Fif" 8.— Varieties OK Hvmen : Virgin hymen, i,conunonesl form (annular); 2, liynien after 
 coitus ; 3, after delivery ; 4, fimliriate liynien ; 5, hymen with narrow slit ; 6, cribriform 
 hymen ; 7, hymen with septum ; 8, horseshoe form. 
 
ANATOMY. 21 
 
 In Hfrurfiirc the whUh of tlio vnj^iim consist of a 
 silicons mcmbrfvno, covmul by stratified stiuanivHis opitlui- 
 lium nnd i)ossossins numorous papillio; a muscuhtr layer 
 inado up of longitudinal and circular fibres; and a_///>/-o?/s 
 tunic of rich fibro-clastic tissue derived from a prolonga- 
 tion of the recto-vesical fascia. The mucous membrane of 
 the anterior wall is thrown into folds or rmja' and a less 
 distinct formation is found on the posterior wall. They 
 are called the (inferior and posterior eolnmns. 
 
 The blood supphj is derived from the vaginal, uterine, 
 vesical, and internal pudic arteries. The Jijmphdtirs 
 from the lower fourth join the lymphatics of the external 
 genital organs and end in the superficial inguinal glands. 
 The lymphatics of the upper i)ortion proceed outward with 
 the broad ligament and joining with those from the 
 oviduct and ovarie.'; terminate in the lumbar glands. The 
 nerves are derived from the inferior hypogastric plexus of 
 the sympathetic and from the fourth sacral and pudic 
 nerves. 
 
 The Hymen is a fold of mucous membrane which 
 closes more or less completely the lower opening of the 
 vagina. It varies much in shape, the most common being 
 two lateral strips which touch one another in the middle 
 line. Sometimes it forms a ring with a round opening, 
 sometimes a crescent, and sometimes it is represented only 
 by a low circular or crescentic ridge, and not unfrequently 
 the border is indented, which condition is not to be con- 
 founded with a iacerated hymen. At coition the hymen 
 is usually torn, but at first child-birth it is so destroyed as 
 to leave only three or four roundish prominences called 
 the c((niiirnJ<t' mjjrtlformes. 
 
 The Uterus is a hollow flattened pyriform muscular 
 organ situated between the vagina below and the intestines 
 above, and between the bladder in front and the rectum 
 behind. It is about three inches long, one and a half 
 inches at its greatest width, and one inch in thickness. 
 
99 
 
 MEDICAL AND SURGICAL OYN^ECdLOGY. 
 
 Of the entire organ, three-fifths belong to the upper part 
 or hotli/ nud two-fifths to the lower part or neck. The 
 body is ahnost fiat on its anterior surface but distinctly 
 convex beliind; the uj)per border is rounded and con- 
 stitutes the/?///Y//^s,• the lateral borders are slightly convex 
 and mark the attachment of the broad ligaments. The 
 neck or vtrvi.r, spindle-shaped in its general outline, is 
 divided into the vdijinal portion, or that part which 
 projects down into the vagina, and the snpravcKjimil 
 portion. The vaginal portion is covered with squamous 
 
 Be 
 Kit;. 9. — ViKGiN Utekus. 
 A. .Vnterior view. B. Median section. C. Lateral section, 
 
 epithet i II tti. the same as covers the mucous membrane of 
 the vagina, and at its lower end is a transverse or rounded 
 operung, the os cxterninn or os uteri. That j)ortion of the 
 cervix in front of the os forms the (interior lip, and that 
 behind the poi<terior tip. 
 
 The interior of the uterus contains a cavity, the uterine 
 earitij. about two and one-half inches long. That portion 
 within the body is triangular in shape wlien viewed from 
 in front, the expaiided base extending between the orifices 
 of the oviducts and the apex corresponding with the upper 
 opening of the cervical canal, or os internum. _ _ .- 
 
ANATOMY. 
 
 23 
 
 Tluit portion within the c.orvix is fusiform in shape and 
 on its anterior and posterior walls are found ridges 
 separated by (h'ep pouclies which go outward and upward 
 and form the (u-hor niUv or palrmv plirativ of the uteruB. 
 
 Structure. The uterine wall is about three-eighths of 
 an inch thick anil is composed of three layers, a mucous, a 
 muscular, and a serous. The miirosd lines the whole 
 cavity and consists of a fKnicd-propria covered by a layer 
 
 Fig. io.— AiUtrior Surface of the Uterus, Superficial Layer. I., Ruiiiid liRaiiient ; T, 
 Tube ; I, iniddle layer ; 2, transverse fibres ; 3. fibres of the rotiml ligament which have 
 spread over the anterior surface of the uterus ; 4, fibres arising from the posterior portion 
 of the round ligament which form loose fohls l)efore they join the median fasciculus; 5, 
 fibres of the cervix uteri ; 6, oblique fibres. 
 
 of ciliated columnar cells. Numerous tubular depressions, 
 the utricular (jlands, lined with ciliated ei^ithelium are 
 found in it. In the cervix the mucosa is thicker, and in 
 addition to the tubular follicles, racemose glands lie within 
 it. Its upper two-thirds is covered with ciliated columnar 
 and its lower one-tlnrd with stratitied squamous epithelium. 
 The niHscitlar coat is divided into three layers, an outer 
 longitudinal which sends prolongations into the oviducts, 
 
24 
 
 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 niul the round, ovnrinn nnd sncro-utorino ligaments; a 
 middle layer of iuterlaciiij^ longitudinal and circular 
 fibres, which are in connection with the muscular coat of 
 the vagina; and an internal traiisverse layer, the lower 
 portion of which is especially develoi)ed to form a sort of 
 sphincter at the os internum. The serous codt is formed 
 by the usual constitutonts of the peritoneum. 
 
 Position. The exact position of the uterus in the 
 living subject is a much discussed question. It may be 
 
 Fig. II. — Diagramni.itic sagittal section of the female pelvis. _ u, uterus; r, rectum; s, 
 symphysis ; v, perineal body ; ii, is beneath bladder. This is the position of the uterus 
 when the ' ladder is almost empty. 
 
 said that the fundus reaches a little above the brim of the 
 pelvis and lies a little to the right side. With the rectum 
 and bladder empty, tlie longitudinal axis of the uterus 
 forms a right or obtuse angle with that of the vagina. 
 
 The Supporting Apparatus of the uterus consists of 
 eight ligaments composed of folds of peritoneum or mus- 
 cular bands or of both passing from the uterus. The 
 vesico-utcrine are two small semilunar folds of peritoneum. 
 
ANATOMY. 26 
 
 ono on either side of tlio moclinn line and pnHsinfjf from the 
 bhuhler to the uterus on a kivel witli the iutemnl os. 
 
 The sdcro-ufcrine nre fohls of peritoneum passing from 
 the cervix to become continuous with the serous covering 
 of the second portion of the rectum. They form the 
 lateral boundaries of Douf/ldi^' j)oi(ch. Between its layers 
 unstriped muscle fibres derived from the outer layer of the 
 uterus extend from the upper part of the cervix to the 
 second sacral vertebra. 
 
 The lateral or broad ligaments are two wide duplica- 
 
 tures of peritoneum, one on either side, extending from the 
 
 side of the uterus to the pelvic wall, forming a jjartition 
 
 between the anterior and posterior pouches. Each jjresents 
 
 four borders. The superior or free border encloses the 
 
 oviduct as far as its fimbriated end and then diverges 
 
 towards the pelvic wall to form the infnmUbnlo-pelvic 
 
 ligament. The inferior border is attached below to the 
 
 recto-vesical far jia and to a mass of connective tissue 
 
 lying at the side of the cervix, called the parametrium or 
 
 parametric connective tissue. The internal border is 
 
 attached to the side of the uterus, and the external border 
 
 to the side of the pelvic wall where it is continuous with 
 
 the obturator fascia. This ligament has two layers, an 
 
 anterior which covers the round ligament, and a jjosterior 
 
 in which there is an opening for the insertion of the 
 
 ovary. Between the layers are found the blood vessels, 
 
 nerves and lymphatics, together with the parovarium, the 
 
 paroophoron, and unstriped muscle fibres which pass from 
 
 the uterus to the pelvic wall. 
 
 The round licjaments, one on each side, are attached 
 to the upper segment of the uterus, below and in front of 
 the oviducts. Each proceeds in a curved direction, first 
 upward and outward, then inward and forward to the 
 internal inguinal ring, through which it passes. After 
 traversing the inguinal canal it emerges at the external 
 inguinal ring to blend with the tissues of the labium 
 
2(i 
 
 MEDICAL AND HUIUIICAL OYN.ECOLOOY. 
 
 mnjus. Th(i li^'niiuMit consists of bundlos of oonnootivo 
 tiH8u^^ mid uiiHtriiH^d inuscK" Hbrt> dorivud from tiu^ utoruH. 
 It at first runs uiid(^r the aiitorior liiyt^r of tlu^ brond 
 liKiimont, but nftorwards lias a poritotieal covoring of its 
 own which, as a rule, stops at the inner rin^. Occasionally 
 the pouch of puritoiunim accompanies it through the ring, 
 forming the cdtuil of Nuck, corresponding to the processus 
 vaginalis in the male. 
 
 Fk;. 12.- Hlooil-vessels of the pelvis; the anterior part of t.'ie pelvis has been removed, and 
 the bladder an<l the anterior vaRinul wall have been partially cut away. The uterus is 
 drawn up and the Kall-jpi' 'ubes are displaced into the iliac fossic. 
 
 Blood Supply . The uterine arteries derived from the 
 internal iliac pass behind the peritoneum on the posterior 
 wall of the pelvis down into the parametrium and form 
 loops in front of the ureters a short distance from the 
 antero-lateral fornices of the vagina. They then pass up 
 between the two layers of the broad ligaments following 
 
ANATOMY. 
 
 21 
 
 the edges of the uterus ns fnr ns the corriuii, uiul in their 
 course they send off at ri^lit jin^U'S brmiehes to the 
 uterus. At the ititenial os brnuclies in front nml behind 
 form, by nn unnHtomosis, the circular artery. 
 
 P"u;. 13. — The ovarian, uterine and vaginal arteries. 
 
 The hjinphdlics commence in the endotJielium, those 
 from the cervix passing to the obturator glands, and those 
 from the body to the internal iliac glands. 
 
 Nerve Supphf. Branches from the second, third, and 
 fourth sacral nerves join with branches from the hypo- 
 gastric plexus to form a ganglion on either side of the 
 
28 
 
 MEDICAL AND SURGICAL OYN.ECOLOOY. 
 
 corvix. From thin ^an^lioti, brnnchw nro (liHtributtHl to 
 tlio utcruH, vaK'ini 'i'>'l bladder. 
 
 The Fallopian Tubes or Oviducts an^ two loii^ 
 HliMider tubcH which (wtciid from tho Huiu'rior aii^h'H of 
 th(^ iitoruH witliiii and aloii^ tho free inar^iuH of tho broad 
 lij^arnoiitH for a diHtauce of from throo to five inches to tho 
 vi(^iiiity of the ovaricH, where each terminates in n funnel- 
 8hap(Hl orifice, the itifnndihiilum. 
 
 Ea(^li tube is divided into three parts. Tlie isthnivs com- 
 prises about the inner third, and communicates witli the 
 uterus by the osliiun internum, an ojjening so small as barely 
 
 Fio. 14. — Posterior View of Left Uterine Appendages: i, uterus; a, F.nllopian tube; 
 3, Fimbriated extremity and opening it the Fallopian tube ; ^, parovarium; 5, ovary ; 
 6, broad ligament ; 7, ovarian ligament ; 8, infundibulo-pelvic ligament. 
 
 to admit a bristle. The amjinlla or middle part is twice as 
 thick, curved, and follows a 8eri)entine course. Its calibre 
 will admit a uterine sound. The jimhrim are the outer- 
 most part, and surround the outer end of the ampulla like 
 a collar with long flaps. One of these, the Jimhria ovarica, 
 is attached to the free end of the ovary and forms a gutter. 
 In the middle of the fimbria) is the outer opening or 
 ostium abdomvi ale. 
 
ANATOMY. .89 
 
 Structure. Tlu^ oviductH nro mndo up of tliroo coats. 
 The mucouH, contiiiuouH with thnt of tho utoruH, proHonts 
 numorous lon^itui'innl foldn whivh increriHo in sizo and 
 comph^xity within thi^ infundibulum, and in lir.od by a 
 Hinghi layer of (uliatiul cohimiiar (ipithdiuin. The muacuJar 
 is made up of an inner (circular and an outer h)ngitudinal 
 layer of uuHtriped muH(!le Hbres continuous with the 
 muscular coat of the uterus. Tlu^ serous coat consisls of 
 the peritoneal investment contributed by the upper free 
 margin of the broad ligament. 
 
 The Ovaries are two oval bodtes situated by tlie s'de 
 of the uterus, bel(.w, beiiind, and to the inner side of the 
 oviducts. Each ovary appears as an apptuidage on the 
 posterior surface of th-* broad ligament. The anterior 
 border alone is attacheil, being inserted there in a hole, 
 as it were, in the posterior layer. The arched posterior 
 border 'i id tlx broad surfaces are covered with hexagonal 
 columnar epithelial cells, the (jcrtuinal epithelium. The 
 dimensions vary considerably with the individual but 
 they usually measure one and one-half inches long, one 
 inch wide, and half an inch thick. The smaller or lower 
 end of the ovary or uterine pole points toward the uterus, 
 to which it is united by a Pbro-muscular band about one 
 inch long, the ovaridu liijaiiient. The upper (uid or tubal 
 pole after being embraced by the arching oviduct receives 
 the lower border of the fimbriated extremity of the 
 oviduct, and is further connected to the wall of the pelvis 
 by the infundibulo-pelvic ligament through which the 
 blood supply is conveyed to the ovary by means of the 
 ovarian artery, a branch of the abdominal aorta. 
 
 Structure. The ovary is divided into an outer part, 
 the parenchymdtous zone or cortex, and an inner, the 
 vascular zone or medulla. The viortex contains the 
 Graafian follicles, and the ova, and occupies the outer 
 one-third of the organ. The medulla embraces the 
 remaining central portions of the organ into which the 
 
30 MEDICAL AND SURGICAL GYN.ECOLOGY. 
 
 V^lood vessels enter through the hilum. The bulk of the 
 organ consists of peculiarly arranged connective tissue 
 and of unstriped muscle fibre, the ovar inn stroma, in which 
 lie embedded the Graafian follicles. Bener '}\ the germinal 
 epithelium it forms a layer of greater density than the 
 adjacent stroma, to which the name tnnicd (Uhiujinca is 
 applied, but it is not an independent envelope. Under 
 the albuginea is found a zone distinguished by the 
 presence of small follicles containing an ovum, the so- 
 called ovisacs or young Graafian follicles. Inside this 
 zone is found another with much larger Graafian follicles. 
 The medulla is composed of connective tissue and 
 unstriped muscle fibre, but much looser in its arrange- 
 ment, and in this the blood vessels are freely distributed. 
 There are usually from six to twelve large follicles in 
 an ovary and it is simply by their increased size that 
 they seem to form a zone inside the smaller ones. 
 In growing they push the surrounding tissues aside, 
 extend deep into the interior of the ovary and at the 
 same time come closer to the surface, until finally all 
 tissue between the follicles and the surface is absorbed 
 aud they are then ready to burst. 
 
 The mature Graafian foUicle appears as a clear 
 elongated vesicle defined from the surrounding tissue by a 
 condensed layer of ovarian stroma, the theca follicnli, 
 which by some is described as composed of two layers, an 
 outer of connective tissue, the tunica fihrosa, and an inner 
 composed of cells and a tine net-work of vessels, the 
 tunica propria. Within these are several layers of 
 epithelial cells, the mcmhrana (/ranulosa, and on one side 
 these cells form a i)rotruding . ass into the cavity called 
 the discus prolifcrus. The follicle contains a fluid, the 
 liq-iior follicnli. In the discus proliferus is embedded the 
 ovum, about O.B m.m. in diameter, inside of which is 
 found a fine membrane, the zona pellncida, or vitelline 
 membrane. The interior is filled with a semi-fluid, the 
 
ANATOMY. 31 
 
 vitellus, inside of which there is a small vesicle, the 
 germinal vesicle, and within this is found a little round 
 body, the (ferniinal ■ j>of. 
 
 On the escape of the ovum the ruptured and partly 
 collapsed follicle becomes filled with blood. Subsequent 
 changes lead to the conversion of the follicle into a corpus 
 luteum, the chief changes in which being produced by the 
 ingrowth and rapid proliferation of the vascular tissue of 
 the follicular wall. The history of the corpus luteum is 
 naturally affected by the occurrence of ijregnancy, instead 
 of being almost entirely absorbed within a few weekn, 
 when fertilization takes place it persists until the 
 end of gestation. It is usual, therefore, to distinguish 
 between the corpus luteum of menstruation and that of 
 jiregnancij. The mode of growth is identical in both, the 
 stimulus of impregnation leading usually to excessive 
 development. 
 
 The Parovarium or Organ of Rosenmuller, a remnant 
 of the Wolffian body, is situated within tlie two layers 
 of the broad ligament, between the outer end of the 
 ovary and the oviduct. It consists of a series of from six 
 to twelve spiral tubules, lying irregularly parallel, and 
 made up of connective tissue, unstriped muscle fibre and 
 columnar ei)ithelium. Additional festal remains in the 
 form of rudimeiitar tubules are found within the broad 
 ligament near the ovary and constitute the parooptioron. 
 
 URINARY ORGANS. 
 
 The Female Urethra is sliort, being only about o^^^, 
 and one-half inches long, and lies beneath the symphysis 
 pubis, firmly embedded within the anterior vaginal wall. 
 It descends from the neck of the bladder in a slightly 
 curvtnl direction, the concavity being forward, to the 
 vestibule, where it terminates in the meatus urinarius. It 
 is surround(Ml by the compressor urethra- muscle and has 
 a sphincter at the meatus. It is about a quart(*r of an 
 
32 MEDICAL AND SURGICAL GYNvECOLOGY. 
 
 inch in dinmetor, but owing to the elastic chnrncter of its 
 tissues is capable of great distension, a feature of much 
 advantage in examination of the bladder. 
 
 The mucous membrane is covered with stratified 
 transitional epithelium, and tubular glands occur near the 
 vesical end. Two small tubes, Skene, s (jlands, lie within 
 the muscular wall and open into the urethra a short 
 distance above the meatus. 
 
 The Bladder is placed betwc-n the pubic bones and 
 the vagina and uterus. When empty it is situated in the 
 true pelvis and is flattened or "Y" shaped; when distended 
 it reaches more or less into the abdominal cavity and is 
 ovoidal. The hdse or fundus is the lowest part of the 
 organ and is connected to the anterior wall of the vagina 
 and to the neck of the uterus by rather firm connective 
 tissue. Three openhHjs are found in it. In front is the 
 internal opening of the urethra, and behind tliere are two 
 fine lengthy slits, where the ureters open into the bladder. 
 The triangular surface between these three openings is 
 called the triijone. The anterior surface has no peritoneal 
 covering and lies against the pubic bones. The posterior 
 surface is covered witli peritoneum down to the level of 
 the internal os. It has three coats, a serous, derived from 
 the peritoneum; a muscular, composed of an outer long- 
 itudinal, and an inner circular layer of unstriped muscle 
 fibre; and a mucous coat which is thrown into folds when 
 empty. This coat contains numerous lacunar and race- 
 mose (jlamls, and is covered with stratified transitional 
 epithelium. 
 
 Lifjaments. The bladder has four true ligaments, two 
 anterior, running from the lower part of the pubis to the 
 anterior surface, and two lateral, from the outer margins 
 of the anterior ligaments to the sides of the bladder. The 
 false ligaments, five in number, are folds of peritoneum. 
 The two posterior are me vesico-uterine ligaments. The 
 lateral extend from the iliac fossro to the sides of the 
 
ANATOMY. 
 
 33 
 
 bladder, and the siiperior extends from the summit of 
 the bladder to the umbilicus. 
 
 The Ureters are two tubes leading from the kidneys 
 to the bladder. They are from sixteen to eighteen inches 
 long and about the size of a goose quill. Starting at the 
 pelvis of the kidney, they run down parallel with each 
 other to the brim of the pelvis and there crossing the iliac 
 vessels slightly below the division of the common iliac 
 
 Fig. 15.— Relation of the Ureters and Uterine Arteries to the Cervix : U, uterus ; 
 Ur, ureter ; A V, uterine artery ; C, cervix uteri ; /', section of the liladiler 
 at the level of the entrance of the ureters through its walls ; Va, vagina. 
 
 arteries, enter the pelvis opposite the sacro-iliac synchon- 
 drosis. They run on the wall of the pelvis backward, 
 downward, and a little oiitward behind the peritoneum to a 
 point near the spine of the ischium. They then bend down- 
 
34 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 ward, forward, and inward to converge towards tlie bladder. 
 They lie outside the internal iliac arteries behind the 
 broad ligaments, running down to their base and tlien 
 under them. They cross the cervix from behind at an 
 acute angle, about one-half inch distant, so as to come in 
 front of and below it. On reaching the wall of the 
 bladder they turn sharply inward and run for half an inch 
 in its wall, finally opening with a sT^nll longitudinal slit 
 in the interior of the bladder. 
 
 The Rectum is formed by the lower end of the large 
 intestine and extends from the brim of the pelvis to the 
 anal aperture. It is from six to eight inches long, and 
 when empty is one and a half inches wide, but is capable 
 of enormous distension. For convenience of description 
 it is divided into three parts. The upper or first portion 
 extends downward, backward, and inward to the third 
 sacral vertebra, and is covered entirely with a fold of 
 peritoneum, forming the moso-rectur ' . The second 
 portion turns forward and extends as far as the tip of the 
 coccyx, but is covered with peritoneum in front only, 
 (Douglas' pouch.) The third portion, about an inch 
 from its end, turns downward and backward at a right 
 angle to the axis of the vagina to terminate in the anal 
 orifice. It has no peritoneal covering whatever. 
 
 Structure. Besides the peritoneal covering already 
 described, it has a muscular coat formed of an outer 
 longitudinal and an inner circular layer of unstriped 
 muscle fibre. At the lower end the longitudinal fibres are 
 intimately interlaced with the levator (ini, and inter n<d 
 antl extermd sphincter muscles. The external sphincter 
 is a voluntary muscle and surrounds the anal opening. It 
 is attached behind to the tip of the coccyx, and in front it 
 blends with the transversus perinei and the sphincter 
 vaginae muscles. The internal sphincter is only a thicker 
 part of the circular layer of the rectum and surrounds tl <> 
 anal canal inside the external sphincter. The mucous 
 
ANATOMY. . 35 
 
 coat, thrown into numerous folds when the rectum is 
 empty, is covered with columunr epithelium and has many 
 glandular pouches. 
 
 Rcldtions. The upper part of the rectum is separated 
 from the uterus by loops of small intestines; lower down 
 it is in close contact with the cervix and vagina, and at 
 the end it forms the posterior wall of the perineal body. 
 
 The Pelvic Peritoneum is a continuation of the 
 abdominal peritoneum and covers more or less completely 
 the organs in the pelvis. In front it passes from the 
 anterior abdominal wall to the summit of the bladder, 
 which it covers as well as the posterior wall down to the 
 level of the internal os. From there it is reflected over 
 the anterior surface of the uterus and the fundus. 
 It then covers the whole of the posterior surface and 
 extends down behind the posterior wall of the vagina for 
 about an inch. It next passes over to the rectum, leaving 
 a pouch between the two folds, Douglas' pouch or the 
 recto- uterine pouch. From the side of the uterus the 
 Ijeritoneum passes out to the walls of the pelvis, forming 
 the broad ligaments. 
 
 The uterus and broad ligaments together divide the 
 pelvic cavity into an antero-inferior and a postero-superior 
 part. In the anterior compartment or utero-alxloiniudl 
 jiouch, we find the utero-vesical and round ligaments. Its 
 lateral parts, ojjjjosite the obturator canal, have been 
 called the obturator or pord-vesical pouches. The pos- 
 terior compartment is divided into a central deep part, 
 Douglas' pouch, and two shallower lateral parts or pora- 
 nterine pouches. The bottom of these has been designated 
 particularly as the retro-ovarian shelres. The sacro- 
 uterine ligaments, one on each side, form the boundaries 
 between the three compartments. On the side wall of the 
 para-uterine pouch is seen the ureter running under the 
 peritoneum. The ovaries project into these pouches and 
 besides contain loops of small intestines. 
 
36 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 Pelvic Connective Tissue. Loose connective tissue 
 is found everywhere underlying the peritoneum, forming 
 one continuous layer. In some plnces it contains adipose 
 tissue. Just above the symphysis there is a layer, the 
 pre-])eritone(d fat, continued behind the symphysis as 
 the retro-pubic fat. Between the base of the bladder 
 and vagina there is a tight layer of connective tissue 
 and on the front surface of the vagina there is a loose 
 layer. A large mass of connective tissue is found on 
 both sides of the cervix, forming under the broad liga- 
 ments the p(i7'(i,metri(i. From the parametric region a 
 thin layer extends between the folds of the broad ligament, 
 and from there is continued into the iliac fossa and 
 lumbar region. 
 
 The Pelvic Floor. Under this heading there remains 
 to be considered three important structures, the pelvic 
 fitscia, the pelvic (Uaphnujm, and the perineal region. 
 
 The Pelvic Fascia is a continuation of the iliac fascia. 
 It is attached to the iliac part of the ilio-pectineal line, 
 and to an oblique line on the posterior surface of the 
 pubic bone. It descends on the inner side of the pubes 
 and ischium about half way down, where a strong sinewy 
 cord, the lohlte line, or tendinous ai :li, extends from the 
 spine of the ischium to the pubic bf le. That part of the 
 fascia covers the obturator internus and is called the 
 ohturdtor fascia. At the arch the fascia splits into two 
 layers, an upper, called the recto-vesical fascia, which 
 bends inward over the levator ani; and a lower, which 
 follows the obturator internus to the edge of the ischium 
 and pubes, keeping the name of the obturator fascia. At 
 the tendinous arch at the upper insertion of the levator 
 ani, the fascia gives off another layer which runs on the 
 outer surface of that muscle and is called the anal fascia. 
 Together with that portion of the obturator fascia lying 
 below the line, the anal fascia forms the lining of the 
 ischio-rectal fossa, and is called the ischio-i'ectal fascia. 
 
'rj*! 
 
 ANATOMY. 37 
 
 The recto-vesicnl fnscia covers the upper surface of the 
 
 levator aui down to the base of the bladder, the vagina 
 
 and rectum. In front a layer forms the anterior, and on 
 
 the side, the lateral true ligaments of the bladder. From 
 
 the under surface of the recto-vesical fascia a prolongation 
 
 surrounds the vagina, and forms a strong ring around the 
 
 vaginal entrance where it joins with the deep perineal 
 
 fascia. From the spine a band goes to the rectum, which 
 
 follows the rectum down as a sheath and disappears 
 
 around the anus. By its distribution the pelvic fascia 
 
 forms an irregular fibrous layer under the peritoneal 
 
 cavity, strengthening the pelvic floor and giving support 
 
 to the organs found in it. 
 
 I Pelvic Diaphragm. Under the pelvic fascia is a 
 
 horse-shoe-shaped muscular expansion, open in front, 
 
 formed by what is generally described as two muscles, the 
 
 leiHitor ani and the coccygeus. It is attached above t;> 
 
 the jjosterior surface of the pubic bones, to the tendinous 
 
 arches of the pelvic fascia, to the front of the spines of 
 
 the ischia, and lesser sacro-sciatic ligaments. From these 
 
 attachments the anterior portion goes backward and 
 
 inward, on either side, some fibres to be attached to the 
 
 urethra; some cross the vagina and are interwoven on its 
 
 lateral aspects with its structures; some loops go from 
 
 side to side between the vagina and rectum, but the 
 
 greater jjart joining with the fascial portion goes behind 
 
 the rectum, grasping the end curve of that tube and 
 
 supporting it. The posterior fibres are inserted into the 
 
 side of the sacrum and coccyx. 
 
 Function. It strengthens the pel /ic floor and forms a 
 strong bed on which rests the uterus and bladder. It is 
 the antagonist of the thoracic diajihragm, being relaxed 
 in inspiration and contracted during expiration, as may 
 easily be seen with a Sims' speculum in the vagina. It 
 lifts the rectum up during defecation and exercises a 
 similar function for the vagina during childbirth. 
 
38 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 The Perineal Region is somewhnt rhomboidal in shape 
 and is bounded by the rymphysis and descending rami of 
 the pubes, by the tuberosities and ascending rami of the 
 ischium, and by the lower edge of the gluteus maximus 
 and tip of the coccyx. It may be subdivided by a line 
 drawn across in front of the tuberosities into two jjarts or 
 triangles, an anterior or uro-yenital, and a posterior or 
 anal region. 
 
 Perineal Fascia and Ligaments. The anterior or 
 uro-genital region has beneath the skin and adipose 
 tissue, n layer of dense connective tissue called the 
 superficial pcrincxd fascia, analogous to that in the male. 
 Beneath this there is another layer, the deep perineal 
 fascia or triangular ligament. It has two layers, a 
 superficial attached at the sides to the rami of the pubes 
 ischium, and in front to the pubic bones, behind it is 
 continuous with the superficial perineal fascia and with 
 the deep layer. The deep layer is likewise fastened to the 
 rami of the ischium and pubes. In front it is continuous 
 with the recto-vesical fascia, behind it is continuous with 
 the anal fascia on the lower surface of the levator ani. It 
 is jjerforated by the urethra and vagina. Where the 
 superficial perineal fascia and the two layers of the deep 
 meet behind, they are fortified by a strong transverse 
 band, the isehio-perineal ligament. In the anal region 
 the anus forms an opening in the median line between the 
 nates, and is there surrounded by its sphincter. Between 
 the rectum and the ischium is a pyramidal space, the 
 ischio rectal fossa. ' 
 
 Perineal Muscles. Situated beneath the superficial 
 perineal fascia there are three pairs of muscles. The 
 ischio-cavernosus or erector-cliforidis is attached at one 
 end to the ramus and tuberosity of the ischium, covers 
 the corpus cavernosum, and at the other end is attached to 
 the free part of the clitoris. The hulbo-cavernosus or 
 sphincter vagina', receives some fibres from the external 
 
ANATOMY. 
 
 39 
 
 Hiihincter niul suporficinl traiiBvorsus perinci, pnsHos for- 
 wnn' on either side nud is attnclied, one part into the 
 posterior aspect of the bulb, another on the mucous 
 membrane between the clitoris and the urethra, and 
 another on the lower surface of the clitoris. 
 The superfwidl trans- 
 
 versiis perinci is attach- 
 ed to the tuberosities of 
 the ischia and to the 
 median raphe. The deep 
 muscles in the uro-geni- 
 tal region are not well 
 developed. They are 
 the compressor urethra', 
 the deep tnmsversus 
 perinei, and the con- 
 strictor vagina', all situ- S^ 
 ated between the two 
 layers of the deep perin- 
 eal fascia. 
 
 The Perineal Body 
 is the name given to 
 the tissues comprised 
 between the genital 
 canal and the rectum, 
 below the point where it turns backward. In shapr it is 
 not always the same. Sometimes it is triangular, with the 
 base down, in some it has an ui^per narrow and a lower 
 broad part, and in others it is : ^arly quadrangular, or has 
 the shape of a quadrant of a ci.cle. 
 
 In structure it is composed of the posterior ends of 
 the bulbo-cavernosus, the fibres of the transversus perinei, 
 the external and internal sphincter ani, and the levator 
 ani muscles, the ischio-perineal ligament, the jjosterior 
 part of the superficial and deej) fascia, the anal fascia, 
 and adipose tissue. It is covered below by the skin, 
 
 Fig. i6. — Dissection ol the Muscles of the Perineum 
 and Pelvic Floor. A. Anus ; li. liulb of the 
 V.igina ; C. Coccyx ; I,. Larger sacrosciatic 
 ligament ; P. I'ernical body ; U. Urethra ; V. 
 V.igina ; Ci. Vnlvo-vaginal gland, i. Clitoris; 
 2. Its suspensory ligament ; j. Crura clitoridis ; 
 4. Krector clitoridis muscle ; 5. Constrictor 
 cunni ; 7. Transversus perinei ; 8. Sphincter 
 ani ext.; 9, 10. Levator ani; 11. Coccygeus ; 
 12. Obturatorjext. 
 
40 
 
 MEDICAL AND SURGICAL OYNiECOLOOY. 
 
 bohiiul by tho mucous mombrano of tie rectum, nnd 
 nbovo nnd in front by tho mucous mombrnno of tho vulvn 
 nnd Homotimes of the vaginn. This body is of great 
 importance by forming the centre of tho whole perineal 
 region, and by its muscles, fascia, and ligaments being fast- 
 ened to the surrounding bones, it bo- 
 comes the chief support of tho whole 
 pelvic floor. 
 
 The blood supphj by means of tho 
 
 internal pudic artery is distributed the 
 
 same as in the male. The nerve sui)ply 
 
 is distributed from the pudic branches 
 
 Fu;. 17.-Trianguiar.si1.-1pe of the sacral plexus and from tho 
 
 of perineal body. pudendal branchos of tho small sciatic. 
 
 Tho lymphatics lead to the inguinal glands. 
 
 CHAPTER IV. 
 
 GYNAECOLOGICAL TECHNIQUE. 
 
 The number who do not believe it necv?ssar to 
 observe stringent precautions in operative surgery is 
 fortunately very small, and is diminishing every day. 
 The study of bacteriology has placed surgical operations 
 on a thorough basis. Every surgeon must have a true 
 conception of the terms sepsis, asepsis, and antisepsis, 
 and determine nt nil costs to apjily his knowledge prac- 
 tically to his everyday work, and in order that he may 
 have a knowledge of the one, and be able to carry out the 
 other, presujiposes n thorough trnining in the principles 
 of bacteriology at least. The scientific application of an 
 aseptic and antiseptic technique can be thoroughly carried 
 out only by observing every detail, even the most minute, 
 the utility of which has been proved by bacteriological 
 research. It is necessary to keep before one's mind an 
 
GYNiECOLOaiCAL TECHNIQUE. 41 
 
 cxaltfd idvii of surgical cloaiilinoHH, rtMin'mbfrinK tlmt ns 
 a chain is no Htron^i'r than its weakest link, ho aHeptio 
 8ur^'ory is only so far aseptic ns the weakest link in its 
 chain. Sucei^ss doc^s not apply alone to the Huceessful 
 termination of larj^e or extiMisive operations, but it ai)plies 
 e<iually to the lesser details of obstetrical as well ns 
 gynteeoU)^ical work. In these as well as in the formor, 
 without that ri^'id attention to surgical cleaidiness, success 
 cannot be expected to follow, but on the contrary, both 
 patient and surgeon mny expect to be doomed to disnp- 
 pointment. 
 
 The term sepsis or septic infection includes nearly 
 all the surgical infections, general or local, resulting from 
 bacterial invasion. The symptoms as a rule are due not 
 so much to tluH bacteria themselves but to their chemical 
 products. When the bacteria have gained entrance into 
 the general circulation and have multiplied there, the 
 system becomes more or less overwhelmed with the 
 bacterial poisons and that condition is called acute 
 sc pi icivmia. Localization of the pyogenic bacteria in the 
 organs give rise to multiple abscess formation, and that 
 condition is called puivmia. The phenomena resulting 
 from the absorption into the circulation of the products 
 resulting from the local growth of putrefactive micro- 
 organisms are included under the term sapnvmid, while 
 the nbsori)tion into the circulation of tlie products result- 
 ing from the local action of infective organisms, consti- 
 tutes an infective toxicmia. General septicaemia or pyjBmia 
 mny be set up by almost any of the micro-organisms 
 which have pyogenic i^roperties, but the most frequently 
 met with in surgical work are the staphylococcus pijofjoies 
 aureus; the streptococcus pyogenes; and the bacillus colt 
 communis. Less frequently we have the stttphylococcus 
 cpidermidis alhus or the staphylococcus pyogenes alhus; 
 the staphylococcus pyogenes citreus; the gonococcus of 
 Neisser; the bacillus pyocyaneus, or the bacillus of green 
 
42 MEDICAL AND BUROKJAL OYNiEUOLOOY. 
 
 puH; nnd the niicrococrus lanrcohttmi, or (llplorncms 
 Itnciniioiiio'. 
 
 The i)riiicii)al iiiicTo-or^niiiiunH coticfriu'd in sup- 
 puration are the micro-cocci (Gk. kokkos, a keruol), a 
 Hinall round body. 
 
 The staph i/loroccus (Gk. staph iilos, a bunch of grapi^H) 
 }>!l<HI<')U's aureus, in more common tlmn any other. It 
 may be hIiowu on the skin, in the secretion of the mouth, 
 beneath the finder nails, in water, in the air, and else- 
 wlu>re. In culture media it forms iarj^e j^olden y(>llow 
 nuisses. It is the most frequent cause of superficial and 
 deep abscesses, nnd it lias often b^^en recognized as the 
 infectious agent in general septicjemia following operations 
 or child-birth. The other varieties of staphylococci, 
 namely, the staphylococcus (^pi(h>rmidis albus, and the 
 staphylococcus pyogenes citreus, differ little from the fore- 
 going, except as their names imply. The staphylococcus 
 epidermidis albus being, for instance, found very abundant 
 on the skin even under normal conditions. 
 
 The streptococcus pijof/enes grows in chains (Gk. 
 strej)tos, a chain) consisting of from four to ten or more 
 cocci. External inflammations due to streptococci are 
 characterized by their spreading character and erysipela- 
 tous redness. It is one of the most frequent causes of 
 post-operative peritonitis; the pseudo-membranous anginas 
 of scarlet fever and measles are, as a rule, due to it, and 
 there is a strong connection between it and the different 
 forms of liuerperal infection. 
 
 The Gonococcus. Much pathological imjoortance has 
 been attached to this organism, and it undoubtedly plays 
 an important part in the inflammations of the tubes and 
 ovaries. 
 
 The (liplococcus pneumonic^ is the causative factor in 
 acute lobar pneumonia, but it is also known to be a definite 
 pus-producer and has been found in acute abscesses, in 
 empycBma, in suppurative c litis media, in quinsy, and is 
 
OYN-EC;<)L()OICAL TE(!1INIQIIE. 43 
 
 not Hii uncomiuon cause of puerperal and sejitic wound 
 infections. 
 
 The hdcilliiH voli rommiuiin is constantly present in the 
 fjuces of man and is more oft<Mi than any other tlu^ cause 
 of acut(> KUpi)urative p(>ritonitiH, especially wln^e there has 
 betui an opening between the lumen of tlie bowel and the 
 peritoncfd (ravity. 
 
 In practising asepsis w(> aim at bringing about the com- 
 plete absence of septic material, a condition in its entirety 
 impossible. Most fresh wounds contain a certain number 
 of organisms even under a strict aseptic technicpie, but 
 either tlu^y are non-virulent or present in too small num- 
 bers to givi' rise to the phenomenon of sepsis, finding 
 the surroundings inimical to growth and multiplication, 
 or they are destroyed completely by the natural protective 
 powcTs of the body tissues. 
 
 The maintenance of an aseptic condition is certainly a 
 most important point to be aimed at in forvnulating a 
 techni(iue, and when formulated it must not app'y alone 
 to surgical operations, but to every detail of minor work in 
 which a lesion in the mucous or serous membranes or in 
 the skin may permit of the introduction of such micro- 
 organisms. 
 
 In practising nHfisrpi^is we employ the various means 
 which have been devised for destroying bacteria or in- 
 hibiting their action, and the agents employed to bring 
 about this condition are called (mtiscptirs. 
 
 Sterilization. Bj' lixis term is meant the process which 
 brings about the absolute and complete destruction of 
 bacteria. The ngpnts chiefly used for the purpose are 
 heat, (Irij and moist, and rhrmicdl (fisinfcvfion. 
 
 For carrying out sterilization by means of drji had a 
 hot air sterilizer is required, and to destroy the ordinary 
 non-spore bacteria requires their exposure to dry heat at 
 a temperature of 100° C. for an hour and a half, and where 
 spores exist, at a temperature of 140°C. for three hours. 
 
 ■l:..^ 
 
44 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 Unfortunntoly the procoss at that ti>mi)ornture will dcHtroy 
 many substances of vegetable^, or animal orij^in, and the 
 metliod has consec^uently been sui)planted by more sptH^dy 
 and less risky methods. 
 
 Hfrrilization htj vioi'st hcaf. Boiling water is one of 
 the quickest agents which we jiossess; ijyogenic cocci and 
 other vegetative bacteria, are destroyed in from one to five 
 seconds, while anthrax spores succumb in two minutes. 
 
 Sterilization hij }<f('(nn is another simple and practical 
 mc^thod. Several kinds of steam sterilizers have been 
 recommended, one of the cheapest and most convenient 
 being the copper sterilizer of Arnold. One of th^ most 
 ingenious methods of ensuring comjjleto disinfection is 
 that known as fractional or (liscontinuons sterilization. 
 It consists in keei^ing the fluid to be sterilized in a steam 
 sterilizer at a temperature of 1(X)°C. for twenty minutes 
 on three successive days. By this means any spores which 
 e8cai)e destruction at tlie first heating will have grown out 
 into vegetative forms and will be killed by the second 
 heating. If the process be repeated for a third time, one 
 can be reasonably sure of a completely sterile fluid. 
 
 Steam sterilization is however not ai)plicable to all 
 objects to be sterilized, as for instance, the hands of the 
 operator, his assistrait, or the part of the patient to bo 
 operated upon. For them chemieal disinfection is required. 
 The ideal chemical disinfection is one that demands a 
 host of qualifications, and when judged by such a standard, 
 no single one fills the requirements. 
 
 Carbolic acid is a powerful antiseptic but a dangerous 
 one. Besides being an antiseptic it is also a deodorant 
 and local ansesthetic. 
 
 Corrosive sublimate. The extreme toxicity of this 
 chemical is well known and some deaths have been directly 
 traced to its use. It has a strong germicidal power, but 
 not absolutely so, besides experiments have definitely 
 provetl that even in weak solutions it injures fresh wounds, 
 
GYNiECOLOGICAL TECHNIQUE. 46 
 
 producing when examined under the microscope n distinct 
 line of superficial necrosis. 
 
 Potdssiiiin p('rm(ni(j(()i(itr, in solutions varying in 
 strength from 1 to 10() to 1 to 10, possesses some germici- 
 dal power. Other chemical disinfectants such as boric (icUl, 
 iKiptliol, and salicylic acid are of questionable usefulness. 
 Tlie day has come • en the use of antiseptics must be 
 rele^gated to the period before operation, and reliance 
 placed during operation in the maintenance of an asei)tic 
 condition. 
 
 THE PRACTICAL APPLICATION OF SURGICAL ASEPSIS. 
 
 Under all circumstances personal hygienic measures 
 are (essential, both as to the condition of the whole body 
 as well as that of the general clothing. It is best to be 
 provided with an operating sidt after some approved plan 
 and so constructed as to leave the arms bare. The suit, 
 previously sterilized, can be slipped on after the removal 
 of the outer clothing and before the commencement of the 
 operation. Not only must the operator and his assistants 
 be thorough in the cicaiisiny of the hands, but all those 
 who in any way aid in the handling of the materials 
 employed during the operation. For this purpose Hunter 
 Robb recommends that the hands and arms be vigorously 
 scrubbed with green soap and water for ten minutes, the 
 water used being as hot as can be borne, and changed ten 
 times. They are then to be immersed for two minutes ia 
 a warm solution of permanganate of potassium; next they 
 are to be washed in a warm solution of oxalic acid; next 
 rinsed in sterilized lime water; next in sterilized normal 
 salt solution; and finally immersed in a 1 to 500 solution 
 of bichloride of mercury. Just before beginning the 
 operation, the hands should be rinsed in sterile salt 
 solution to rtMuove any excess of bichloride. The use of 
 the permanganate and oxalic solutions have either never 
 been used or have been abandoned by many good surgeons 
 as affording no additional safety. 
 
46 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 One of the newest methods employed for hand disin- 
 fection is chlorine, produced by mixing household chlor- 
 inated lime with crystallized carbonate of soda. Its 
 chemical action is a little obscure, but it is virtually a 
 production of the so-called chlorinated soda in a fresh and 
 liquid state and is better known by the familiar name of 
 Labarraque's solution. It is used in the following way : 
 After thorough scrubbing with hot water and green soap, 
 as already described, and the nails carefully cleaned, a small 
 tablespoonful of the ordinary commercial chloride of lime 
 or bleaching powder is put in the palm of the hand and 
 on it is placed a crystal of carbonate of soda or common 
 washing soda about one inch wide and lialf an inch thick 
 (of a size that will permit it to be easily rubbed about like 
 soap). A little water is now added to made a thick cream, 
 and this is rubbed up and down the hands and arms, and 
 well under the finger nails, until the little rough grains of 
 chloride of lime disappear or markedly diminish, or until 
 the creamy fluid thickens into a pasty mass. This pro- 
 cedure should last about five minutes, after which the 
 paste is washed oft' in sterile water. After the final wash- 
 ing the hands will be found smooth, soft and smelling of 
 chlorine. If the odor persists after the operation it may 
 be removed by washing in a one-fifth per cent, solution of 
 aqua ammonia. 
 
 Its efficiency cannot be doubted, for out of forty-two 
 tests made according to the foregoing method, forty gave 
 sterile results. 
 
 It is advisable to have a patient who is to undergo 
 some very serious operation, such as an abdominal section, 
 in bed and under observation for a few days prior to oper- 
 ation. Light nourishing food should be given until the 
 last twenty-four hours, when the diet is to be restricted to 
 milk or broths. The bowels should be moved daily, and 
 on the night before the operation a purge should be given, 
 followed the next morning by a rectal enema. 
 
GYNECOLOGICAL TECHNIQUE. 47 
 
 The field of operafinn may be rendered prncticnlly 
 sterile by the following procedures, supposing it to be a 
 section : 
 
 (1) A bath of soap and water and a vaginal douche 
 daily for three days. 
 
 (2) On the evening before operation the abdomen and 
 pubes are shaved. 
 
 (3) The parts thoroughly scrubbed with soap and 
 water, then with ether, and then with bichloride of 
 mercury (1 to 1000). 
 
 (4) A compress of bichloride (1 to 1000) is afterwards 
 to be applied, and kept there until the patient is brought 
 to the operating table. 
 
 After being antesthetized and placed on the table, the 
 field of operation is again scrubbed with alcohol or ether, 
 next with bichloride (1 to 1000), and finally irrigated with 
 sterile salt solution. 
 
 Trivial operations upon the uterus or vagina should be 
 carried out with the same due regard for the dangers of 
 infection. On the evening preceding operation a cathartic 
 is given; the external genitals are cleared of hair and 
 scrubbed after the manner of the preparation of the 
 abdomen, the vagina carefully douched with bichloride 
 solution (1 to 5000), followed by sterile water, and 
 the parts carefidly covered over with a large sterile 
 occlusion pad. On the following morning a rectal enema 
 is given, and after being anesthetized, the vagina is 
 scrubbed with a sponge charged with green soap and 
 water, and after irrigating to remove the excess of soap, it 
 is washed with a warm solution of bichloride, and then 
 with sterile salt solution. 
 
 Instruments should be so constructed that they can be 
 readily taken apart and cleaned, and of such material as 
 to permit of easy sterilization. The method of Schimmel- 
 busch is by far the most convenient and effective for 
 general employment, and consists of boiling the instru- 
 
48 MEDICAL AND SURGICAL CxYN^COLOGY. 
 
 ments for five minutes in n one-per-cent. solution of 
 carbonate of soda. Any ordinary dish will serve for the 
 Ijurpose, but it is convenient to have a specially 
 constructed apparatus of copper fitted with some sort of 
 heating apparatus, if stationary, a Bunsen burner. A flat 
 wire basket fitting into the boiler will facilitate the 
 introduction and removal of the instruments. 
 
 Trays made of thick glass are the most satisfactory 
 vessels in which to keep the instruments at the time of 
 operation. By the use of hot water or steam they are apt 
 to be broken, brt they may be rendered sterile by first 
 washing them thoroughly with water and then filling them 
 to the brjm with, or immersing them in a solution of 
 bichloride (1 to 500), in which they are allowed to remain 
 for an hour. Just before being used they are washed out 
 with sterile water' and filled with enough of the same to 
 cover the instruments. 
 
 In the choice of sutures and ligatures certain 
 points must be taken into consideration. No suture 
 material will suffice for all purposes, but whatever is iised 
 the main points to be considered are, that it must be 
 sterile, smooth and pliable, but not brittle. The substances 
 commonly employed are surgeon's cable twist silk, 
 numbers 1, 2, 3, 4 and 5; silk worm gut, fine and coarse; 
 kangaroo tendon; and catgut, sizes A, B, C, D and E. 
 For the preparation of silk lufdturcs or siitHvcs, each size 
 after being cut in appropriate lengths are wound on 
 sejDarate glass reels. On one reel there should be at least 
 four heavy ligatures, three feet long; on the second, ten 
 intermediate or deep ligatures, eighteen inches long; on 
 a third, ten smaller for superficial ligatures, eighteen 
 inches long; and on a fourth, ten small, also eighteen 
 inches long, for fine sutures. The four reels after being 
 put into an ignition tube and the moutii plugged with 
 cotton batten, are sterilized in an Arnold steam sterilizer 
 for one hour the first day and for half an hour on each of 
 
GYNAECOLOGICAL TECHNIQUE. 49 
 
 the two succeeding days. Tlie tubes so prepared may be 
 kept in glass jars, but for safety it is best to re sterilize 
 what may be required immediately before every operation. 
 
 Silk-worm (jut is a substance admirably adapted for 
 suture material. It is smooth, easily introduced, is non- 
 absorbable, and resists the invasion of bacteria much 
 better than silk or catgut. In preparing it for use, the 
 twisted ends of the strands being cut off, eighteen of them 
 are folded once and placed in a glass tube in which they 
 are to be kept. They are then sterilize.l after the manner 
 described for the sterilization of silk ligatures. 
 
 Cdffiut is, in many ways, the ideal material for sutures, 
 but unfortunately there is no method of rendering it 
 absolutely sterile. Notwithstanding the most careful 
 preparation, suppuration sometimes follows its use. Many 
 well known surgeons, having sufficient confidence in their 
 methods of sterilizaticm, use it not oidy for sutures but 
 for small and even large i)edicles. The following are a 
 few of the most reliable methods for its preparation: 
 
 (1) The raw material is placed in ether for seventy-two 
 hours; next in an aqueous solution of bichloride of 
 mercury (1 to 1000) for twenty-four hours; next in oil of 
 juniper for forty-eight hours; after which it is to be 
 transferred to absolute alcohol. 
 
 (2) After being in ether for twenty-four hours, it is 
 transferred to a solution of bichloride (1 to 100) in eighty 
 per cent, alcohol, and changed daily for three days; after- 
 wards it is preserved in absolute alcohol. 
 
 (3) After being soaked in ether for twenty-four hours 
 it is wound in three feet lengths on reels, and jjlaced in 
 botth^s plugged with cotton batting. The bottles are then 
 placed in a water bath and heat gently applied until the 
 alcohol boils for five minutes. The boiling process is 
 repeated for three days after the method of fractional 
 sterilization. 
 
50 MEDICAL AND SURGICAL GYNyECOLOOY. 
 
 (4) The catgut is put in ether for a j^e. od of from two 
 to seven days, according to tlie size of the gut, the ether 
 being changed once. It is then transferred to a solution 
 of bichloride in alcohol (1 to 500) for from two to seven 
 days, after which it is i)reserved in a solution made by 
 dissolving two ounces of iodoform in four ounces each of 
 alcohol and ether. 
 
 (5) Five volumes of the formal of commerce with from 
 forty to one hundred volumes of formaldehyde are turned 
 into one hundred volumes of distiiieJ water. The threads 
 to be sterilized are placed in a small i^ask in a glass and 
 filled with the solution until the mouth cf the flask is im- 
 mersed, the top of the glass being protected with filter 
 paper moistened in a solution of formalin (5 to 100). It 
 is kept at the temperature of the room for twenty-four 
 hours. The formal is re^jlaced by alocliol, which dissolves 
 the little formalin remaining, and after decanting again the 
 flask is filled with alcohol and covered with the formalin 
 filter paper. This method is advantageous as it requires 
 no apparatus, no heat, no difficult manipulation and is 
 applicable to all ligatures, catgut, silk, hair and rubber 
 material. 
 
 (6) Modified Kroniij method. 1. Roll the catgut, 
 twelve strands, in a figure-of-eight form so that it can be 
 slipped into a test tube. 2. Bring the tube up to a tem- 
 perature of 80° C. and hold it at that point for an hour. 
 3. Place in cumol which must not be above 100° C, raise 
 it to 165° C. and hold at that point for one hour. 4. Pour 
 off the cumol and either allow the heat of the sand bath 
 to dry the catgut or transfer to a hot-air oven at a tem- 
 perature of 100° C. for two hours. 5. Transfer the rings 
 with sterile forceps to the test tubes previously sterilized. 
 In drying or boiling the catgut it should not come in con- 
 tact with the bottom or sides of the vessel, but should be 
 suspended or placed upon cotton loosely packed in the 
 bottom of the beaker glass. 
 
GYNiECOLOGICAL TECHNIQUE. 61 
 
 On the part of some surgeons there is nn nnxiety 
 felt lest the life-time of the catgut may not be sufficient 
 to accomplish the objects for which it was used. 
 If absorbed too soon, there is a fear of recurrent 
 hemorrhage or gaping of an incompletely healed wound. 
 To overcome this difficulty various methods have been 
 adopted for hardening it, the principal agents being 
 chromic acid and bichromate of potash. The catgut is, 
 as usual, soaked in ether for twenty-four hours; it is then 
 placed in a one-per-cent aqueous solution of chromic acid 
 for from twelve to twenty-four hours, according to the 
 density required; next in a fifty-per-cent solution of 
 sulphurous acid for twenty-four hours; next in an 
 alcoholic solution of bichloride (1 to 5(X)) for twelve 
 hours, after which it is preserved in absolute alcohol. 
 
 Kan(f(iro() tendon possesses many excellent qualifica- 
 tions. It is smooth, pliable, strong, and not too readily 
 absorbed, from eight to ten weeks being usually required 
 for its disappearance. After being treated according to 
 one of the methods described for the preparation of catgut, 
 it is preserved in a solution of carbolic acid in oil (1 to 20). 
 When re(iuired, the necessary number are removed with 
 aseptic forceps, placed momentarily in ether to remove 
 the oil, then wrapped in a sterile towel saturated with hot 
 bichloride solution until they are used, when they will 
 be found clean and soft. 
 
 Dressings. When a wound is not to be closed hermet- 
 ically it is important to apply a dressing which, while 
 being free from pathological bacteria, will prevent the 
 advent of micro-organisms fiom the outside and at the 
 same time absorb the secretions from the wound and jjre- 
 vent their subsequent decomposition. There is upon the 
 market to-day an abundance of what is known as "anti- 
 septic dressings" and "gauzes" which are often of great 
 utility in the management of wounds when the surrounding 
 circumstances and conditions render their use necessary. 
 
52 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 Good (ihsorhmt cotton in rolls and common chfesc cloth 
 will suffice for nil ordinary surgical dressings. The cheese 
 cloth may be prepared by cutting it in lengths of two 
 yards and boiling for half an hour in a one-per-cent. solu- 
 tion of carbonate of soda, and then rinsed in sterile water 
 and rolled up. Atmovtwnt cotton, (jauzcs and l)(in(l<i(/cs, 
 wrapped in towels, may be sterilized by exposure fo" three- 
 quarters of an hour to the steam of an Arnold sterilizer, 
 after which, if not rolled or packed too tightly, may be 
 considered absolutely sterile. Iodoform (jonzc is occas- 
 ionally required for various purposes. The gauze, made 
 ready after the manner already described, is immersed in 
 an iodoform mixture, prepared by mixing enough castile 
 soap with twelve ounces of a one-per-cent. aqueous solu- 
 tion of carbolic acid to make good suds, after which 
 fourteen drachms of iodoform are added and thoroughly 
 mixed. Pernio n<j(m(ttc (jduze is not unfrequently used 
 for dressings, having no objectionable odor in itself and 
 has the power of diminishing the odor of foul smelling 
 discharges. It is prepared by saturating sterilized gauze 
 with a one-per-cent. aqueous solution of permanganate of 
 potash. 
 
 Sponges. Either the ordinary marine sponges or 
 substitutes made from sterilized gauze are the ones chiefly 
 used. Marine sponges are more elastic and pliabl(> than 
 any other material, but unfortunately they cannot be 
 sterilized by steam without ruining them, and other 
 methods do not always render them absolutely sterile. 
 They may be prepared by first pounding them in a muslin 
 bag to remove all particles of sand and then rinsed in 
 several changes of water. If so desired they may now be 
 bleached by placing them for twenty minutes in a warm 
 solution of ijermanganate of potash (half a drachm to two 
 pints of water). After being rinsed in warm water they 
 are them immersed in a warm solution of hj posulphite of 
 .soda (one and a half ounces to two pints of water), to 
 
GYNJICOLOOICAL TECHNIQUE. 53 
 
 wliich Imlf an ounce of hydrochloric acid hos Just hern 
 (i(l(l('(L and allowed to remain in it until (initc white. 
 After bein^f thorou^'hly Hoaked in water they are next 
 plaet'd in a bichloridi^ wolution (1 to 5(X)) for twelvH- liourH, 
 and after bein^ again washed in sterile water they are 
 transferred to glass jars containing a three-per-cent. solu- 
 tion of carbolic acid. Gauze sp(ni<ics may be made by 
 wrapping absorbent cotton somewhat loosely in squares of 
 gauze, the corners bcung brought together at the top and 
 tied with a thread, or they may be allowed to remain tlat, 
 the edges biung folded under and hemmed. 
 
 Drainage. A few years ago nearly ninety per cent, of 
 all cases of abdominal section were drained, now not more 
 than ten per cent, are drained, but as it is yet indispen- 
 sable it is necessary to decide ui)on the safest and best 
 means. Where tubes are emi)loyt'(l those made of glass 
 are the best as they can be readily sterilized. When 
 drainage is absolutely necessary, as in cases of wide spread 
 injury to the cellular tissue of the j)elvis and it is impos- 
 sible to check the bleeding, or in cases where a cavity has 
 been opened, the walls of which can not be entirely 
 eradicated, or in cases where the pelvis has become in- 
 fected by the rupture, accidental or otherwise, of a puru- 
 lent formation, the ordinary glass drainage tube has been 
 supplanted by iodoform gauze. To make it most effectual, 
 the gauze is pushed down to the bottom of the cavity, 
 either inserted in a sausage-shaped bag or in long strips 
 placed in position by the aid of dressing forceps or sponge 
 holders, the free ends being brought to the outside through 
 the abdominal wound or through the vagina, should the 
 pelvic cavity be opened through that route, or drainage by 
 that route desirable. 
 
 Irrigating fluids. The routine treatment of irrigation 
 of the pelvic cavity in every case cannot now be considered 
 a necessary i)ractice. Where the structures are non- 
 adherent and there have been no special complications, 
 
5-4 MEDICAL AND SUmUCAL OYN.FX'OLOGY. 
 
 thoro would hihmii to bi^ no indication for itH (Mni)lovnu>nt, 
 but lifter till' romovnl of a mass whii'li coutains bloody 
 fluid, or whi>re there has been a ^reat deal of oozing, 
 irrij^ation may sometimes be useful. If the fluid whii^li 
 has escaped be of a septic nature, irrigation is more likely 
 to spread it further between the coils of the intestines 
 than to remove it. 
 
 In selectiiifif a fluid, it is necessary to endeavor to 
 secure one that will ^ive the best results with a minimum 
 amount of harm. The fluid most generally used is plain 
 water rendered sterile by boiling and when r'^quired for 
 irrigation may readily be brought to the required tem- 
 perature, 105° F., by having two vessels, one containing 
 hot and the other cold water. The jirinciiwl objection to 
 its ase is that it has a definite deleterious effect upon the 
 tissues, and to overcome this difficulty, nornud salt 
 sol lit ion is extensively used. It is so prepared as to 
 correspond very closely in specific gravity with the normal 
 serum of the blood. Common salt, in the proportion of 
 forty-five grains to the pint, is dissolved in sterile water, 
 and after being put in sterile flasks and plugged with 
 cotton is sterilized by fractional sterilization. Before 
 operation, two flasks are re-sterilized and one is kept hot 
 while the other is allowed to cool, and when they are 
 required they are mixed to the proper temperature in a 
 graduated jar containing a thermometer. 
 
 The use of strong antiseptic solutions, such as 
 bichloride of mercury and carbolic acid, must be unhesi- 
 tatingly condemned, and in the use of mild ones, such as 
 boric and Thiersch's solutions, it may be said that they 
 possess no advantages over the ordinary sterile water or 
 salt solution. 
 
 Some form of dry powder is frequently used to dust 
 over the abdominal wound or after plastic operations, and 
 the ones most in use are boric and iodoform powders. 
 The penetrating odor of iodoform is a strong objection to 
 
GYNJICOLOGICAL TECHNIQU— 55 
 
 it, nncl it is not to bo forgotten that somo pnticntH nro 
 t'xtnMnc^ly HUH(H'ptiblo to its toxic efftn^ts, but on the other 
 hand it in the best germicidal powdc^r in UHe. A coinbiiia- 
 tiou of iodoform one part and boric acid wevon parts in 
 an excellent mixture, having the advantage of being non- 
 irritating to the skin as pure iodoform sometimes is. 
 
 INSTRUMENT LISTS. 
 
 It is important to write out lists of the instruments 
 that are used in different operations and to keep them 
 where they can easily be consulted. 
 
 INSTRUMENTS FOK AN ABDOMINAL SECTION. 
 
 A8[)itiitor. Nozzles. 
 
 Catheters. Retractors, large. 
 Cautery (l'u<iueliii). " next size smaller. 
 
 Forceps, long dressing. Kubber tubing for [jedicle. 
 
 " long liii-mostatic. Rubber tubing. 
 
 " medium liii'mostatic. Scali)el8. 
 
 •• small hiumostatic. Scissors, long. 
 
 " bullet. •' short. 
 
 " rut-tooth. Sound, uterine. 
 
 Drainage tubes. S(»eculum, Sim's. 
 
 Irrigator. Sponge-holders. 
 
 Needles, large. Tenaculum, straight. 
 
 " transfixion, right curved. " curved. 
 
 " " left curved. Trocars, large and small. 
 
 " " straight. Two Ntilaton's forceps. 
 
 Needle- holder. 
 
 INSTKUMENTH FOR VAGINAL HYSTERECTOMY. 
 
 Catheter, glass. Needles, transfixion, straight. 
 
 Curettes, dull and sharp. Needle-holder. 
 
 Forceps, dissecting. Retractors. 
 
 " lonp^ hit'mo8t«tic. Sealjiels. 
 
 •' medium hamostatic. Scissors, long and sliarp-pointed. 
 
 " small hii-mostatic. Sj)eculun», Simon's, with handles 
 
 •' bullet. and four blades. 
 
 Needles, curved, large, medium Sound, uterine, 
 
 and small. Sponge-holders. 
 
 Needles, transfixion, right curved. Tenaculum, straight. 
 
 INSTRUMENTS FOR PERINEORRHAPHY. 
 
 Catheter. Retractor, small. 
 
 Forceps, hivmostatic. Scalpels. 
 
 " long dressing. Scissors, right-angled, 
 bullet. " left-angled. 
 
 " rat-tooth. " straight-pointed. 
 
 Needles. Sound, uterine. 
 
 Needle-holders. Tenacula. 
 Nozzle, glass. 
 
56 
 
 MEDICAL AND «U1UHC!AL (lYN/ECDLOGY. 
 
 Ciithotor. 
 Cui'ulluH, (lull and Hhnip. 
 Diliitoi'H, (litl'ureiit HJ/es. 
 ForoepH, liiiiiioHtutic. 
 
 " It'll^f < I I'OHhI !!{:;. 
 
 *' rat-tooth (lre88iiig. 
 bullet. 
 Irriyiitor. 
 NeocUes, asHorted HJzeH. 
 
 IN8TRIIMKNT8 FOR TBAOHKLORKHAPIIY. 
 
 Neodlo-lioldei'M. 
 
 Noz/.lo, j^laBH. 
 
 Retractor, Hiiiall. 
 
 Scalpels. 
 
 HcJHHorH, Htraifflit and curved. 
 
 Bound, uterine. 
 
 S|>eoulinn, Sim's, or Simon's with 
 
 haiulleH and four blades. 
 Tenacula. 
 
 INSTRUMENTS KOR DILATATION OK CERVIX AND CURETTINCJ OK UTERUS. 
 
 Catheters. 
 
 Catheter, irrigatinj^ two-way. 
 Curettes, sharp and blunt. 
 Dilators, three sizes. 
 Forcei)s, bullet. 
 
 " long dressing. 
 
 Forceps, rat-tooth. 
 
 Nozzles, glass. 
 
 Sound, uterine. 
 
 SjHiculum, Sims's, or Simon's with 
 
 handles and four blades. 
 Tenaculum. 
 
 LIST FOR ABDOMINAL OI'KRATIONS OUTSIDE OK HOSPITAL. 
 
 Aspirator. 
 
 Instruments in bags. 
 
 Basins for instrument*. 
 
 Cautery (Piuiuelin). 
 
 Coats for doctors and nurses. 
 
 Solutions : bichloride (1 to 20). 
 " crude carbolic acid. 
 
 " normal salt. 
 
 Crystals of permanganate of potas- 
 sium and oxalic acid. 
 
 Soap and two brushes. 
 
 Rubber sheets and ovariotomy pad. 
 
 Sterilized towels. 
 
 Ether and cone. 
 
 Chloroform and inhaler. 
 
 Hypodermic syringe. 
 
 Brandy. 
 
 Strychnine tablets (,5'j grain). 
 
 Rubber tubing. 
 
 Si)onge8. 
 
 Silk ligatures, four sizes (.3 tubes). 
 
 Catgut ligatures, three or four sizes. 
 
 Silkworm-gut. 
 
 Scultetus bandage. 
 
 Safety-pins. 
 
 Sterilized gauze. 
 
 Strips of gauze for dressing. 
 
 Celloidin. 
 
 Sterilized cotton. 
 
 Iodoform gauze. 
 
 Iodoform and boric acid powder. 
 
 Glass graduate. 
 
 LIST FOR PERINEAL AND OTHER MINOR OrEKATIONS. 
 
 Instruments. 
 Leg- holder. 
 Ligatures. 
 Sterilized stockings. 
 Perineal pad. 
 
 Douche bag. 
 Dressings. 
 Bandages. 
 Cotton pledgets. 
 
.ETIOLOGY IN (lENEUAL. 57 
 
 CHAPTER V. 
 
 .ETIOLOGY IN gi:ni:ral. 
 
 The causes of the diseases of women arc niniiily 
 Httributnbl(> to tlio orrors, (lir(>ot or indirect, of modi^rn 
 life. Tlioy may be tlius clnssifi'/d: 
 
 1. Abnormalities produced by hereditary congenital 
 deficiencies of development. Tho dofectivo heredity 
 is probably not generally immediate but a gradual 
 deeleunioii, for tlie most part on the maternal side, 
 tending, by continuous de^eni*ration, to induce in the 
 progeny feeble sexual formation. For instance, the first 
 stage may be found in a woman having a uterus of 
 moderate development, but contracted at its opening, and 
 which becomes lacerated in her first confinement. The 
 offspring, possessing a feebly developed uterus, becomes 
 pregnant by chance, it may be long after marriage or 
 after an operation; or she may have a congenitally 
 contracted upper vagina ; or a tendency to infantile pelvis, 
 with absence of sexual appetite. She becomes the mother 
 of one child who has yet a feebler unimpregnable uterus, 
 with atrophic ovaries and deficient and most likely pain- 
 ful catamenial discharge. 
 
 2. Abnormalities produced by congenital or sub- 
 sequent arrest of development owing to the effects of 
 bacterial action. The eruptive fevers, as measles, scarlet 
 fever, small-pox and probably syphilis also, by the action 
 of their toxines, directly conveyed to the embryo by 
 absorption from the maternal blood, destro_y the vitality 
 and power of growth of the germinal genital cells. After 
 birth and at any time previous to fail development, these 
 causes and, along with them tubercalcsis, may effect and 
 destroy the vitality of the growing cells. The destruction 
 of vital force in the special germ cells produces arrest of 
 development, and as a result congenital deficiencies and 
 arrest of development are found ,in the pvaries, oviducts. 
 
58 MEDICAL AND SUR'ilCAL GYNJICOLOGY. 
 
 uterus, vaj.^ina, hymen, or vulva. Should the development 
 of the genital ridge be deficient or arrested, the ovaries 
 are so undeveloixnl that they are unable to arrive at their 
 successive montldy maturity, whence arise amenorrhosi and 
 sterility. If the growth of the upper part of the Mullerian 
 ducts ceases, the oviducts are minute or defective, By 
 the absence of fusion, complete or pat-tial, of tlu^ two 
 Mullerian ducts in the genital cord, the uterus is double 
 or bifid. From arrest in one duct and development in the 
 other, the unicorn uterus results, and, after the normal 
 fusion, cessation of vital growth may (^ause the uterus to 
 be diminutive. In a similar manner there may bo two 
 vaginae, or one defective in size, or no vagina at all. 
 
 A uterus, normal in length, but with feeble develop- 
 ment and deficient in strength, may have a feeble cervico- 
 corporeal junction and which, as a result, Ik likely to fall and 
 be converted into the position of anteflexion. Coincident 
 with this there is usually dericiency in the size of the 
 opening. Owing to such a condition, the secretions 
 collect within the cavity, are diflScult to expel, and as a 
 result there will arise cervicitis and dysmenorrhcea. In 
 a strong uterus, with a deficiently developed os, there is 
 liability to laceration at parturition, and if the laceration 
 bo double, e\ersion of tlie lips and grarular erosion nre 
 likely to follow. If the fresh raw surfaces of a laceration 
 absorb septic germs, pelvic cellulitis results. Should the 
 perineum be deficient in development or rigid, laceration of 
 it is likely to take place, and when septic infection occurs in 
 connection with a lacerated cer\ ix, subinvolution of all the 
 genital structures, as a rule, res ilts. With subinvolution 
 comes the various forms of uterine misplacements. With 
 subinvolution and misplacement, aided by special mic- 
 robes, as those of gonorrhoea or of the imerperal septic 
 infections, comes endometritis. With its extension to the 
 tubal mucous membrane, comes salpingitis and ultimately 
 by overflow of its contents through the fimbriated ex- 
 
.ETIOLOGY IN GENERAL. 59 
 
 tromity, arises localized peritonitis or abscess formation. 
 Thickening of the tunic of the ovary succeeds local 
 inrtanimatory action and, as a consequence, there follows 
 painful ovulation and various forms of degenerative 
 changes in the ovaries. 
 
 3. Hereditary constitutional defects in which certain 
 classes of cells morbidly proliferate forming tumors. 
 Tlie aetiology of the dermoid tumors is attributable to the 
 origin and mode of development of the ovfry. From the 
 mesothelial di ision of the mesoderm the ovary is formed. 
 The mesothelial layer of the mesoderm is closely connected 
 with the ectoderm. From the ectoderm are developed the 
 epidermis and epidermal structures, such as hair, nails, 
 glands, the eye, and the mouth cavity with the teeth, all 
 of which structures are occasionally found in the dermoid 
 cyst. Thus, in the formation of the dermoid ovum, some 
 ectodermal cells have by inclusion been incorporated with 
 the mesothelinl layers and, continuing to grow, produce a 
 cystic tumor with skin-like walls and containing any or 
 all of the structures formed by the ectodermal layers. 
 
 The pdrororian cijst is caused by an embryonic 
 deficiency of absorption and a subsequent hypertrophic 
 glandular secretory development of the cylindrical lining 
 cells which normally remain quiescent in the sexual part 
 of the female rudimentary Wolffian ducts, sitrated in the 
 connective tissue of the broad ligaments, and known as 
 the parovarium. 
 
 As to the n3tiology of ovdrian cystomo, in the develop- 
 ment of the ovary, portions of its germinal epithelium 
 grow inward and some of the cells become ova while 
 deeper multiple cells of the same description form the 
 membrana granulosa. The i)ormal function of these cells 
 is to conduce to the nutrition and further development of 
 the ovum. It occasionally happens that the tendency to 
 continuous proliferation of the cells of this layer is greater 
 than required and there is multiplication in excess. At 
 
60 MEDICAL AND SURGICAL GYN/ECOLOGY. 
 
 the snme time the inner cells rujituro nnd pour their 
 secretion internally Jirul by such continuous process an 
 ovarian cystoma is formed which persistently enlarges. 
 The degeneration being of a type which effects the 
 develoi)ment of all the cells of Ihis class, the disease does 
 not attack one follicle alone, but is common to all; hence 
 the cystoma, on its attainment of some size, is almost 
 always multilocular. 
 
 Mijowa, which is a proliferation of unstriated muscle 
 fibres enclosed in a connective tissue capsule and usually 
 multiple, is attributable to absence of pregnancy, from 
 whatever cause, in a woman of strong sexual development. 
 
 Carcinoma or cancer, which is a continuous cell pro- 
 liferation, of epithelial type, invading the lymi:)hatic spaces 
 and vessels and always originating in epithelium derived 
 from the ectoderm or entoderm, has its cause in such sites 
 and conditions as induce excessive formation of cells of 
 degenerating quality. Such sites and conditions are 
 exceedingly common in the chronic granular hyperplastic 
 face of the lacerated cervix. 
 
 Continued irritation from any cause, for instance 
 of a myoma, may prodv ce a constant proliferation of a 
 primary or embryonic type in the connective tissue and, 
 as a result, a sarcoma of the round or spindle celled 
 variety is produced. 
 
 4. The training and effects of education. The long 
 confinement in-doors during school hours, frequently with 
 impure air; the absence of exercise of arms and legs, 
 tending to stagnation of circulation; the stooping posture; 
 the increased attraction of blood to the brain and great 
 call upon the mental powers; improper exercise; the 
 personal competitions culminating in place examination; 
 all have their deleterious effect and tend to develop mental 
 at the expense of physical power, and producing as well, 
 constipation, auiemia, irritable hypersensitive nerves and 
 derangement of the menstrual function. 
 
iETIOLOGY IN GENERAL. 61 
 
 5. Personal habits. That care, so necessary at each 
 menstrual epocli, is not as scrupulously observed as it 
 should be, and at times injurious consequences, of a tem- 
 porary or permanent nature, result. Of all the injurious 
 influences to which is attributable the great mass of 
 disease now so prevalent, the greatest is the custom of the 
 alteration of the form of the body and of the position and 
 relations of the internal organs by compression of the 
 lower thorax and abdomc^n, by means of corsets. The 
 influence is markedly accentuated by the attacliment of 
 the skirts and petticoats around the waist and abdomen. 
 In pregnancy the corsets are often worn tight so as to 
 conceal the condition. Society often demands the ex- 
 posure of the neck, arms and should(>irs to the suddenly 
 varying temperatures of heated ball-rooms, corridors, 
 verandahs, and gardens, while closely associated with 
 these are, improper diet, irregular meals and late hours. 
 The influences of absence of marriage, of late marriag(\ 
 and of ineffective marriage, which includes artificial pre- 
 vention of pregnancy, are highly deleterious. 
 
 (). Sexual exhaustion arising from an insatiable sexual 
 appetite, leads to (h^bility, to weakened nervous system, 
 and chronic congestion resulting in endometritis. 
 
 7. Infectious diseases. Tlie effects of syphilis are seen 
 in hereditary congenital and in simjjle forms. In the 
 fornu^r, malformations are present at birth; in the latter 
 the results, similarly causfMl, may not manifest themselves 
 for varying periods after birth. The mother may directly 
 transmit measles, scarlet-fevci, find small-pox to the f(t)tus. 
 To gonorrhoea is to be ascribed a series of progressive 
 diseases, which are as liable to be as virulent as they are 
 continuous. Septicannia, induced primarily by the en- 
 trance into the system throxigh the blood vessels or 
 lymphatics of micro-organisms, may, if it does not prove 
 at once fatal, produce wide spread damage. Tuberculosis 
 in the geiutal organs may occur by the arrival of the 
 
62 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 tubercle bncillus by the intestines, by the blood, or 
 through the vnginn. 
 
 8. Lastly may be mentioned those diseases and con- 
 ditions due to operative causes, niuong which may be 
 mentioned the introduction of dirty instruments; the 
 application of irritants; forcible dilatations; injections of 
 fluids into the uterus; pessaries; exploratory jiunctures; 
 and the improper treatment of abortion. 
 
 CHAPTER VI. 
 
 ANESTHETICS. 
 
 The entire civilized world owes a countless debt of 
 gratitude to Dr. W. T. G. Morton of Boston, the discoverer 
 of the anesthetic properties of sulphuric other; and to 
 Dr. James Y. Simpson of Edinburg. who, a year later, 
 discovered chloroform. Much time has been consumed 
 in discussing the relative merits and demerits of the two 
 agents. The views of surgeons regarding their relative 
 values vary widely, but there can be no doubt each of 
 them has its advantages and disadvantages. 
 
 In the administration of such powerful drugs, the 
 fact must not be lost sight of, that they are not free from 
 danger, and in the selection and administration o^ an 
 anesthetic, the question of safety should dominate all 
 others. Despite every precaution, and every care taken 
 in their administration, sudden death occasionally will 
 occur. For a long time chloroform was enthusiastically 
 held in favour in this as well as in other countries, but it 
 has gradually been supplanted by ether, on account of its 
 greater safety. From statistics collected with the greatest 
 care, it has been shown that the mortality from chloroform 
 anresthesia is about one in five thousand, and that from 
 ether, one in twenty thousand. From careful experiments 
 
ANAESTHETICS. 03 
 
 and observations it has been proved that chloroform 
 exerts a steady, powerful, depressing influence on the 
 heart, by its action on the heart mus o or its contained 
 ganglia, and, consequently, a large number of deaths from 
 chloroform are due to cardiac arrest. When chloroform 
 paralyzes the respiration, it does so by its direct action 
 ujjon the resi)iratory centre. 
 
 The study of the action of ether on the circulation 
 goes to prove that the primary influence of the drug is to 
 stimulate both the vaso-motor centres and the heart. In 
 etherization there is usually a pronounced rise of arterial 
 pressure which is commonly maintained, even through a 
 prolonged narcosis, and may continue after manifest 
 failure of respiration. 
 
 Fatal syncope, by the direct effect of chloroform upon 
 the heart, is the common cause of chloroform death. On 
 the other hand with ether, the direct effect of which is to 
 stimulate the heart, death from syncope is rare. 
 
 Notwithstanding the greater safety of ether, there 
 are c{rciiiiisf(tu<'('s iDlti'cli nuHllftj flic choice of (tiKCfifhciics. 
 Old people, where the chest has become rigid, do not 
 seem to respond sufficiently to the demand made upon 
 them by ether, but bear chloroform well. 
 
 Ill obesity also, ether is often not well borne, producing 
 much excdtement and rt^spiratory irritation, chloroform 
 being often necessary to secure tranquility of breathing. 
 In the presence of ovfjditic brain diseoses, including 
 tumors, the dangers of aiuDsthesia are increased. 
 
 Wide spread (dheroma should give to the surgeon, who 
 desires anresthesia, much anxie'^^v, and when demanded, 
 chloioform should be given the preference. 
 
 In dif«'<ifies of the licart, ether is usually preferable to 
 chloroform; indeed where the h(^art is very feeble, or the 
 cardiac muscle degenerated, chloroform becomes a very 
 dangerous remedy; and where orthoijnoia exists, its use is 
 never justifiable. 
 
84 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 A mixture composed of nlcohol, one part; chloroform, 
 two parts; nnd ether, three jmrts; commonly known as the 
 A.C.E. mixture, if freshly mixed, may be chosen with 
 advantage in cases of atheroma, obesity, and valvular 
 disease of the heart. The local irritant effect of ether on 
 the mucous mmnbrane of the air tubes contraindicates its 
 use in extensive emphysema, in chronic bronchitis attended 
 by expectoration, in dyspnoia, and in advanced pulmon- 
 ary phthisis. In such cases, if anaesthesia is necessary, 
 chloroform should be employed. In obstructive laryngeal 
 disease or where there is contraction of the trachea, either 
 from within or without, the greatest caution must be 
 exercised, for the irritating effects of ether will increase the 
 tendency to mechanical asphyxia. Both ether and chloro- 
 form have a distil ct deleterous influence upon the kidncijs, 
 but, of the two agents, etlier is the more dangerous. The 
 great danger arises from swppressiou of urine and death 
 from ura^.mia. There are L^iome jjatients who, although 
 ai)parently healthy, liave sensitive bronchial mucous 
 membranes, show a high rate of respiration in cither 
 anjBsthesia, and cough, even in deep anjesthesia. In such 
 cases chloroform should be at once substituted. 
 
 Both before and during the administration of ether 
 or chloroform, certain instructions should be rigidly kept 
 in mind. 
 
 1. Analy7A> the urine, especially before the administra- 
 tion of ether; also examine carefully the heart and lungs. 
 
 2. Examine the mouth for false teeth or foreign boditss. 
 
 3. Loosen the clothing to prevent constriction of the 
 circulation or respiration. 
 
 4. Cause the patient to assume the dorsal decubitus, 
 with the head resting low on a small pillow. 
 
 5. Anoint the face with vaseline to prevent irritation 
 or excoriation. 
 
 6. Instruct the patient to close the eyes and to take 
 deep, full and regular respirations. If excitement or a 
 
ANESTHETICS. 65 
 
 dread of danger occurs during the early inspirations, it is 
 well to drop the mask and, in a few kind words, calm and 
 encourage the patient. 
 
 7. Chloroform must be administered slowly and mixed 
 always with a sufficient quantity of air. If ether is given, 
 the precaution is unnecessary and may delay anitjsthesia, 
 but in case of cyanosis, breatlis of pure air should be 
 allowed until the cyanosis has disappeared. 
 
 8. Do not commence oi)eration until anresthesia is 
 complete, indicated by paralysis of the palpebral reflex, 
 and by relaxation of the voluntary muscles. 
 
 9. Secure good ventilation. 
 
 10. Watch carefully the pupils, dilatation or their 
 failure to respond to light must be viewed as a sign of 
 apprc )aching danger. 
 
 11. Watch carefully the pulse and respirations. Quick- 
 ening of the respirations, as well as weak pulse or respira- 
 tion, may denote that too much aiiffisthetic has been given. 
 Loud stertor in chloroform anaesthesia is an alarming 
 symptom, indicating epiglottidean closure of the larnyx. 
 
 12. Remove from time to time the mucous which is apt 
 to accumulate in the mouth or throat by means of a small 
 sponge on a holder. 
 
 13. Watch the color and expression of the face; 
 lividity indicates asphyxia. 
 
 14. Allow no solid food for five hours at least before 
 operation, nor should liquid food be allowi^d later than 
 three hours. 
 
 15. Very nervous individuals should receive a hypoder- 
 matic injection of a quarter of a grain of morphia twenty 
 minutes before the ansBsthetic is commenced. 
 
 All plans of administration now in use may be 
 arranged under two headings: o^x'U (Khiiinisfration, 
 which admits of the free access of air, and closed <«hnin- 
 istration, in which the patient breathes out of and into a 
 bag, with a more or less imperfect supply of air. 
 
66 MEDICAL AND SUROIOAL GYNAECOLOGY. 
 
 Open ethorizntion may bo prncticod by simply foldiiip^ 
 ft towel ill the form of n coiio nnd puttiuj^tlio other iusido; 
 or by making a cone of thick material which fits tightly 
 to the face, at the apex of which a sponge is placed to 
 receive the other. 
 
 Allis' inhdler consists, essentially, of a series of folds of 
 muslin on a wire frame-work and surroundcnl by a soft 
 rubber cover. It allows the air to pass freely through, 
 mixed with the ether, and, when properly used, does away 
 with the sense of suffocation and the consequent struggles. 
 
 Closed t^thorization is performed by means of an inhaler 
 such as Clover's or Ormsby's, which are so constructed 
 that the patient breathes in and out of a receptacle con- 
 taining ether, the amount of air admitted being regulated 
 by a stop-cock for that purpose. When ether is first 
 administered, it should be small in amount and largely 
 diluted with air, after which the air may be gradually 
 withdrawn and the ether pushed more energetically. The 
 patient passes through a stage of bewilderment, the face 
 becoming flushed, the respirations rapid and the pulse 
 accelerated. This is followed by one of excitement, which 
 afterwards passes into a state of muscular relaxation. 
 While administering ether, the fact must always bo borne 
 in mind that its vapor commonly kills by asphyxia and 
 not by syncope, henco, though the pulse is to be watched, 
 the respirations should be the principal object of solici- 
 tude, and tlu^ first appearance of dangerous symptoms 
 should b(> met by prompt and suitable remedies. 
 
 Chloroform may be administered by means of a towel 
 placed over the patie^it's face, but it is best given on an 
 Esmarch's mask, which consists of a wire skeleton covered 
 with canton flannel. It fits loosely over the nose and 
 mouth, thus admitting air freely, while the chloroform is 
 dropped on it, a few droi)s at a time without its removal. 
 After inhalation for a few minutes, consciousness is lost, 
 the conjunctivae becomes insensitive, and the breathing 
 
AN-ESTHETICS. .67 
 
 assumes a somewhat stertorous character. Before com- 
 plete aujusthesia, convulsive movements, accompanied with 
 cj'anosis, often take place. It is best in such cases not to 
 straggle with tlie patient, but to discontinue inhalation 
 until the cyanosis has disappeared. During the entire 
 period of administration, the finger should be kept over 
 the temporal artery and the respirations watched. A 
 patient may die, either on account of asphyxia or on 
 account of heart failure, the latter being by far the most 
 frequent cause. 
 
 Failure of the pupils to respond to light, or tlieir wide 
 dilatation is a sign of apijroaching danger. This, together 
 with paleness of the face, biueness of the finger nails and 
 a weak, tlickering pulse, should cause the anaesthetist to 
 at once npply proper remedies. 
 
 ^A^henever dangerous symptoms threaten, the aufes- 
 thetic should be discontinued, either wholly or for a time 
 at least. If the respirations become impaired or the pulse 
 very weak, it may be possible to finish the operation with- 
 out further administration. When the symptoms of 
 resjairatory impediment do not yield promptly, place the 
 fingers behind the angles of the lower jaw and force the 
 jaw forward. If the breathing does not then promptly 
 become normal, seize the tongue with forceps and pull it 
 forward. If ordinary means do not suffice to restore 
 breathing, resort must be had to (irtijiciiil rcspiratt'on, 
 aided by lowering the lu^ad and elevating the body in a 
 position similar to that of Trendelenberg. These efforts 
 may be aided by flipping the chest with a wet towel or by 
 the application of the poles of a Faradic battery, one polo 
 over the phrenic nerve in the U'^ck and the other over the 
 diaphragm. The question of the use of drugs in threat- 
 ened accidents is a very important one. Hypodermatic 
 injection of ether possesses no advantages, but rather, in 
 cases of ether anresthesia, increases the difficulty. Alcohol 
 in the shape of brandy or whiskey is an excellent stimu- 
 
68 MEDICAL AND SURGICAL GYN.ECOLOGY. 
 
 lant, but gives best results only when the cardiac failure 
 results from hemorrhage or other surgical cause. The 
 influence of hypodermatics of digitalis, or its alkaloid, is 
 very pronounced, increasing the arterial pressure and the 
 size of the individual pulse beats. Amyl nitrite, for which 
 much has been claimed as a cardiac stimulant, has some 
 effect in increasing the pulse wave, but it must be con- 
 sidered as a doubtful remedy and used with great caution 
 in anaesthetic syncope. The best results are obtained from 
 the hypodermatic injection of strychnia. It causes a 
 gradual rise of the arterial pressure and an immediate and 
 extraordinary increase in the rate and depth of respiration. 
 In order to get the best effect from the alkaloid it is 
 essential to give it in large doses. To a robust individual, 
 with serious anjBsthetic heart or respiratory failure, one- 
 eighteenth of a grain may be given at once. 
 
 CHAPTER VII. 
 
 EXAMINATION IN GENERAL. 
 
 GENERAL OUTLINES OF DIFFERENTIAL DIAGNOSIS. 
 
 When a patient presents herself for advice and 
 treatment, the first essential to a full understanding of her 
 case, is a complete history. The subject naturally resolves 
 itself into two parts, the history of the patient f. I the 
 physienl examination. 
 
 THE HISTORY OF THE PATIENT. 
 
 The first interview between the patient and the 
 doctor is an important one, and it is a very good rule to 
 allow the patient time and oijportunity to state lier case 
 fully. Not only what is said, but the manner in which it 
 is said, will give the physician an insight into her dis- 
 position and character and will enable him to treat her 
 
EXAMINATION IN GENEUAL. 
 
 ()«.) 
 
 mf)n> intclliKriitly mid succoHHfully. The iuv(>Hti^ation 
 nuiy bt' codvciiii^iitly curried out by observing nnd mnking 
 note of the t'ol lowing points. 
 
 A printed form for ennt^-taking, while not esKential, is 
 of great advantage. It Faves time and suggv sts objec^ts for 
 incpiiry, wliieh n.ight bo overlooked, and, besides, is of 
 gn^nt advantage in the subsequent study of the cases. 
 
 FORM FOR CASE TAKING. 
 
 Pkehknt Complaints and their Dukation, 
 
 1. Hixlory : 
 
 Family Hi .story 
 
 Previous Diseases 
 
 First appearance 
 
 Regularity 
 
 Duration 
 
 Amount and character 
 
 Pain, before, during, 
 
 or after 
 Confined to bed 
 Last appearance 
 
 Date. Pregnancy, 
 
 / At full term 
 
 o 
 
 9! ' 
 
 X 
 
 ' In head 
 In back 
 In abdomen 
 j^ In legs 
 
 During coitus 
 In sitting 
 In standing 
 ,In walking 
 
 Labor. Puerperium. 
 
 o 
 
 n 
 
 .Premature 
 
 '^ g j Amount 
 
 '■^ < [ Character 
 
 ^ y I Persistence 
 
 > £5 Duration 
 
 Appetite 
 
 Cause of illness (supposed by 
 patient) 
 
 2. SlalUH PraneiiH : 
 
 General Condition 
 
 Condition of the Nervous System 
 
 Constitution 
 
 Breasts 
 
 Urination 
 Defecation 
 
 Digestion 
 
 Abdomen 
 
 Vulva 
 
 en 
 
 Pi 
 H 
 E-c 
 
 Position 
 Size 
 
 Mobility 
 Shape 
 
 Depth of Cavity 
 '.Secretion 
 
70 MliDlOAL AND SURGICAL GYN.RC'OLOOY. 
 
 
 Pori Ileum 
 
 
 I'HHJtioil 
 
 
 Viiginii 
 
 
 Kliape 
 
 
 Uvoiu\ i^ipimeiits 
 
 'A 
 
 IjtiuiitU 
 
 
 TllhuM 
 
 >, 
 
 Density 
 
 
 OvariuM 
 
 «1 
 
 .Secretion 
 
 
 DouffliiH' I'diich 
 
 Internal ()« 
 
 
 BIjk (lor 
 
 
 Kxternal On 
 
 
 Urethra 
 
 
 ^Lacerateil 
 
 
 liectiim 
 
 
 
 
 Coinpli(;atioiis 
 
 
 
 3. 
 
 Didiiuoiis : 
 
 
 
 4. 
 
 Trtatmeut ami ProiirtiMs : 
 
 
 
 The age of tlu^ pationt has a cliriHit b(>aring on many 
 mattiTH. suoli as mrnHtruation and child-boaring, and will 
 often throw much light on tho nature of the distiase. 
 Cancor rarely occurs before the thirtieth or fortieth year, 
 and more often about the time of the menopause. 
 
 Social condition and occupation has often a material 
 bearing upon the disease from which the patient suffers. 
 It is of the utmost importance to know whether she sijends 
 her time in sedentary pursuits, or, as a shop-girl, kept 
 standing or walking about all day long; or, as a charwoman, 
 whose daily round is one of severe toil <ind often hardship. 
 Information as to whether the patient is single, married, 
 a widow, or separated from her husband, is often a 
 necessary factor in deciding important questions. 
 
 Leading symptoms in the case. An important point 
 is to enquire what brought her to seek advice. In the 
 majority of cases it will be found that actual pain in some 
 part or other is the leading symptom. In other cases 
 pain may be entirely absent, or only i^resent under certain 
 conditions. Others may sj^eak of a swelling in the 
 abdomen as the leading feature. It sometimes happens 
 that the patient complains only of some trivial deviation 
 from health, yet, if her case be gone into systematically 
 and carefully, important information will be forthcoming, 
 which will enable us to suspect the nature of the trouble. 
 
 Menstrual history. At the outset, in order to arrive 
 at a correct opinion as to the contlition of the menstrual 
 
EXAMINATION IN (lENliUAL. 71 
 
 function, it iH lUHH'HHnry to nHcortaiii tlu^ normal cluirm't(ir 
 of iiuMiHtruatioii in the individual, for thrro am ainon^^ 
 woini'U wid(^ individual diH'cnMU'CK consiKtcnt with health. 
 The [)oints to which attention should be directed are: 
 
 1. The (Kjc of rommrurcmcnL Men»trnation usually 
 coinnitUKU's botwct^n tho ages of thirteen and fourteen 
 years, but it is often seiMi earlier than that time and 
 occasionally does not appear until later. Climate, race, 
 and accidental causes often bring about a n nrked differ- 
 ence in the time. 
 
 2. RIiijIIdii of flic Jloir. It sometimes liapptMis that aft(^r 
 tlu^ first period or two, the patitint sees nothing again for 
 some months, perhaps for a year or more, and after that 
 time, recommences and continues regularly. With most 
 women the flow comes on every twenty-eight days, but in 
 some it appears at shorter intervals, and iji some at long(>r 
 intervals than normal, while in others the menses do not 
 appear with any regularity. On careful enquiry it will be 
 found that the peculiarities are natiiral to the individuals 
 and that the irrcigularity must be looked upon as regular 
 for them. 
 
 3. Diirdfion of the floir. In the majority of women the 
 period lasts four or five days, but here again consid(>rable 
 variation is found, within physiological limits. In some it 
 lasts only a day or two; in others the flow continues seven 
 or eight days, without the presence of any abnormal 
 condition. 
 
 4. The (hiilij omount. In this also there is consider- 
 able room for variation, some soiling but few napkins 
 throughout the whole period, while- others have to change 
 very frequently. Enquiry as to how often the napkins 
 have to be changed and the degree of soiling at each 
 change, will give a fair estimate of the amount lost. 
 
 5. The (iffoidaiit si/nipfonis. In some patients there is 
 no pain and no discomfort, but as a general thing, as the 
 flow approaches, there is a sense of fulness, congestion, 
 
72 MEDICAL ANb SURdlCAL GYNiiCOLOGY. 
 
 disturbance and weight in the pc^lvic organs; often there 
 is pain in a greater or Ivaa (logree. Sometimes it is 
 a'^'companied by general disturbance, iiharacterized by 
 frontal, occipital, or general headache, and by nausc^a and 
 vomiting. The time at which the jmin begins varies in 
 different individuals. In some the pain will begin a day 
 or two before the flow, in others a few hours before, while 
 in others it comes on with the flow. 
 
 0. Lcuvorrluvd. In a healthy woman there is no dis- 
 charge, but some women have almost naturally a little 
 discharge of a whitish character for a day or two after the 
 flow cef "' s. Discharge c £ a thick glairy mucous in large 
 quantities is however pathological. 
 
 7. Abnormal iHuu'aiions. The menses, previously 
 normal, may have become too frequent or quite irregular; 
 the duration or daily loss may have increased or dim- 
 inished; or pain, previously absent, may have become a 
 promiiAont symptom. In any case we should ascertain, 
 how far the condition deviates from he: previous normal 
 condition; what the change has been and .he time at 
 which it set in. At the menopause the menses are often 
 irregular; occasionally they stop for a month or two and 
 even longer, then a re;^ulai period or two follows, after 
 which they cease altogether. Sometimes they suddenly 
 cease and the patient sees nothing more; in others again, 
 the menopause is ushered in by considerable floodings. 
 It must always b< borne in mind, especially in the case of 
 flooding, that women are particularly liable to malignant 
 disease at that time. 
 
 Both for future reference and as a guide to the 
 advisability of examinntion uy ineans of the sound, 
 enquiry should be made, as to the date of the onsot of the 
 last period and the time at which the last period closed. 
 
 The obstetric history. Tt is most important to have 
 the obstetric history of the patient, the history of her 
 labo.s and miser, riages, if any, because a very consider- 
 
EXAMINATION IN GENERAL. 73 
 
 ablo ninount of illness which presents itself, is tlie result 
 of impregnation nnd of disease following upon delivery or 
 a., rtion. Ascertain the number of the chihlren, the 
 character of each hi})or, tli<^ date of last delivery, whether 
 there have been any premature labors or miscarriages, 
 and, if so, whether any particular cause can be assigned 
 for the occurrence. 
 
 Illness during pregnancy and after delivery. Ascer- 
 tain whether the health continued good during pregnancy. 
 Unusual symptoms at that period are to be carefully 
 enquired into. Illness after delivery is usunlly of a 
 febrile character and the cause in nearly every case is 
 attributable to septic mischief. 
 
 Previous illnesses. Ascertain from the patient the 
 nature of previous illnesses and whether associated with 
 the ptdvic organs or not. Many of the troubles comi)lained 
 of will be found to date from illness occurring at or soon 
 after delivery or miscarriage. 
 
 The history of the present illness. Ascertain, first of 
 all, the date at which the present illness began, also the 
 cause assigned for her illness. Of the particular symptoms 
 to which attention should be drawn, pain stands first, 
 because it is one of the most common. The site of the 
 pain must be noted, whether it be continuous or spasmodic, 
 and its chav<(cf('v, whether it be sharp and cutting or dull 
 and aching, and also whether it be associated witli 
 icnderuess. Pain or tenderness is a symptom of a very 
 considerable number of diseases to which women are 
 especially liable, such as pelvic peritonitis, parametritis, 
 disease of the cellular tissue of the pelvis, luematocele, 
 hicmatoma, inflammatory diseases of the appendages, 
 metric.. s, adhesiotis left from previous inflammations, and 
 finally tumors in the uterus, tubes o" ovaries. 
 
 Dyspa;eunia may occur from various causes and is 
 fre(iuently associated with vaginismus. It may be prim- 
 ary, tlii '; is, it may have existed from the beginning of 
 
74 MEDICAL AND SURGICAL OYN.ECOLOGY. 
 
 attt'mpt.s at iioitus, or it :nay liavo ronxe on nftorwards. Tt 
 may arise from i-oM^iMiita! di'tVcts, HssurcH about tlu' vulva, 
 inflamed eonditioiis of the vau^iua, s])eei(ic or otherwiKc, 
 iiiid it may be found in association with urethral earunele, 
 or even with rectal tissurt' or piles. Tlio pnin is sometimes 
 periotlieni, that is, associated with tlu> monthly periods, 
 and, when so apiumring. becomes (me of the most prominent 
 symi)toms of dysmi'n<)rrh(i>a. Ascertain where tlu^ pain is 
 situated, whi'ther it extends into the liips. down tlu> thi,tz:lis, 
 or for a c()nsideral)le distance over the abdomen; al"o 
 when tlu' i)ain bej^ins, whetlier bi^fore the tlow or with the 
 flow, and if before the tlow, the length of time before. 
 
 Menorrhagia and metrorrhagia are often symptotns 
 of severe trouble, and any deviation from the normal How, 
 j)articularly if exttMisive. is to be carefully encpiinHl into. 
 It may arise sim[)ly as the residt of sonu^ constitutional 
 disturbance, as aiiivmia. clilorosis, purpura, but is often a 
 prominent symi)tom in pelvic hiematcHude and lut^matoma, 
 extra-uterine pregnancy, fungous endometritis, mucous 
 polypi of the cervix, fibroids or myoma of the uterus 
 projecting into tlu uterine cavity, subinvolution after 
 continenient. and maligiuxnt disi-ase of the uterus. 
 
 Amenorrhoea. During pregiuincy, as well as during 
 lactation, amenorrluim is the ride, but the menses some- 
 times persist (hiring the early months of pregnaiu^y and 
 even later. Many women will c \tinue to have their 
 periods regularly during nursing, comi .icing sometimes 
 a month after delivery, and it is finite poss'bte UiV a woman 
 to become pregnant during lactaiion. even if the menses 
 have not appeared. It is necessary to renember these 
 facts, because patients are apt to be misled in conseciuence, 
 and. even when far advanced in pregnancy, are not aware 
 of their condition. 
 
 Local swelling or tumors. We should ascertain 
 h'oin the patient if any swelling, either in the abdomen or 
 in the genitals, has be"n noticed, where the swelling first 
 
EXAMINATION IN GENERAL. 75 
 
 jippciirc'd, if [HTKistcnt or vnriablo in its olmnvcitor, tlie site 
 where it was first noticed and the direction in whicli it 1ms 
 ^rown. 
 
 Urinary symptoms. Note the elinrneter of the pain, 
 if prt^sent, and tiie tinn^ at whic^li it (K!curs, whether dnrin^, 
 previous to, or foUowing inieturition. Note also the 
 frequency of micturition and whether it takes place more 
 often at nij^ht than during the day. Inquire if there be 
 difficulty in gc^tting tlu> water to pass, or whether tlie water 
 constantly runs away or is i)assed involuntarily on coughing 
 or straining. The clmrat^tt^r of the urine may be partly 
 learned from the patient, but should always be tested by 
 a proper urinalysis. 
 
 Intestinal symptoms. Ascertain the frequency with 
 whicn the bowels are relieved and if defecation be painful, 
 difficult or associated with tenesmus. Note the condition 
 of the tongue and incpiire as to the digestion, and whether 
 nausea and vomiting be present; and. finally, ascertain 
 what i>r<'ri<)iis trcdhticid, if any, has been adopted, how 
 long it has been carried out, and with what results. 
 
 PHYSICAL EXAMINATION. 
 
 In the majority of cases correct inferences cannot Ije 
 deduced fnnn verbal statements alone, and a physical 
 examination becomes essential. The chief exception to 
 this rule is in the case of young girls. It is most often 
 for irregularities of menstruation and for leucorrham that 
 young unmarried women seek relief, and as these dis- 
 orders, in their casi\ are frecpiently depiMident upon the 
 general health, hygienic measures and drugs will often 
 accomplish all that is necessary. In fact only when such 
 measures have been faithfully tried and proved ineffective, 
 or when there is clear evidence of pelvic disease, is an 
 examiiuition justifiable. Most examinations may be satis- 
 factorily made with the patitmt. if at her home, lying in 
 her bed or on a lounge, or it' the examination is to be 
 
76 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 C50iulnct(Kl in tho office, upon a conveniently arranged 
 couch or chair. 
 
 Position. The two cliief positiouH are the dorsal and 
 Situs'. Of U>ss importance are the (jciiu-jtci'toi'dl, the 
 ci'crf, and TrcniU'li'iibcrifs. 
 
 In the dorsal position the patient lies upon the back; 
 the head slightly raised; the knees drawn up and widely 
 sei)arately; and, if necessary, the heels fixed in some kind 
 of holes or stirrups. It is the best position for digital and 
 bimanual examination, and is often employed for ordinary 
 treatment, on account of its convenience. 
 
 In Sims'' position the patient is i)laced on tho left side; 
 the left side of the face rests on a cushion; the left breast 
 touches the table, and the left arm is placed behind the 
 body. Both knees are drawn up, the right being a little 
 nearer the head and in front of the left. This position 
 allows the introduction of one or two fingers high up 
 behind the uterus, permits the use of Sims' speculum, and 
 does not require such a degree of exposure as the 
 dorsal. 
 
 In the Trcndclcnhcry position, the knees are raised 
 high above the head so that the body slants upward from 
 the shoulders. It is rarely used for diagn(^stic purposes, 
 its chief advantage lying in the additional facilities it 
 offers the surgeon in operations upon the pelvic organs. 
 
 In the (jenu-pectoral position the patient rests upon 
 her knees, the upper part of the chest, the right side of 
 the face and the right forearm. It is sometimes used to 
 replace a retroverted uterus or prolapsed ovary. 
 
 The erect position is used to discover a prolapsed 
 uterus, a cystocele or rectocele. 
 
 Examination under anaesthetics. Nearlj' all exam- 
 inations can be made with a full knowledge on the part of 
 the patient, and it should be a rule to examine first in *,hat 
 manner, but it is sometimes impossible, under such 'r- 
 cumstances, to obtain satisfactory results. Occasionally 
 
EXAMINATION IN GENERAL. 77 
 
 palpation is so painful that the patient cannot endure the 
 slightest manipulation, and, even when no pain is present, 
 it is often found that as soon as the hand touches the 
 abdomen, the muscles, more especially the recti, at once 
 become so tense that it is impossible to feel anything 
 that may be beneath them. Under such circumstances 
 the use of an anjusthetic is not only justifiable, but 
 absolutely necessary, to make a correct diagnosis. 
 
 Methods of examination. Three methods, under 
 ordinary circumstances, are made use of: The visual, the 
 Dumudl or (lujital, and the instruiiicntal. 
 
 VisiKil hispcctioii of the external genitals will often 
 reveal many facts, such as atresia of tlici hymen, swelling 
 of the vulvo-vaginal glands, the presence of papillary 
 growths, venereal ulcers, discharges, urethral caruncle, 
 a lacerated perineum, or prolapse of the vaginal walls. 
 
 Difjitdl ('.rainiii((tion per vfufiHdin. The fingers, 
 especially the index fingers, are instruments of the 
 greatest value in acquiring iid'ormntion, the sense of 
 touch replacing that of vision. The partly closed hand, 
 with the index finger extended, is passed along the inner 
 side of the thigh and, on reaching the vulva, abnormalities 
 of the labia may be detected. The index finger is gently 
 pushed between them into the vagina, examining at the 
 sanu^ time for any peculiarity of the hyuKni, obstructions, 
 pr()la^)sed organs, or gaping from relaxation or laceration. 
 The vaginal walls are palpated to detect abnormalities in 
 them, or of the rectum, or of the urethra or bladder. The 
 finger end next reaches the cervix and is swept around to 
 examine the fornices. By palpation, tlu^ size, shape, and 
 consistency of the cervix and the shape of the external os 
 are made out. The fingers i)ushed up h'lhind will (h^tect 
 a retroverted uterus or displaced ovary, and, when pushed 
 up in front, will feel an anteflexed uterus or ti'e trigone 
 of tiie bladder. 
 
78 MEDICAL AND SUROICAL GYNECOLOGY. 
 
 Dtjfital cxfimivaiioii x>er rectum is best porformod in 
 Sims' position. Besides ovideiico of disease of the rectum 
 obtained by this method, it is n useful method to empk)y 
 in the case of virgins with sensitive liymen or small vagina. 
 Sometimes the uterus and appendag(>s are better felt from 
 the rectum than from the vagina, and, in case of abdominal 
 tumors, valuable information is to be obtained tluuH^by. 
 Abnormal conditions of the coccyx, such as ankylosis or 
 fracture, can be detected at the same time. 
 
 Bi'iikoukU examiiuition. In order to secure the re- 
 quired information it is often necessary to make use of 
 both hands. With one index finger impinging on the os, 
 after the method already describcnl, the other hand is 
 placed above the pubes and the finger tips pressed down 
 with increasing firmness until the fundus is felt and the 
 organ made to lie between the examining fingers of the 
 two hands. If the body of the uterus is not found, it 
 should be sought for either in front of or beliind the 
 cervix. By this method, the outline, size and shape of 
 the uterus can be made out. By pressing well down 
 beside the uterus, the tubes and ovaries may be palpated, 
 and the method is of the utmost advantage in the diagnosis 
 of pelvic tumors. 
 
 Instrumental examination. The vaginal spcoiJiini is 
 an instrument, by the aid of wliich we are enabled to look 
 into the vagina and to treat various pathological conditions 
 found. Of these there are a great variety, but the number 
 may be reduced to three types, the cylindrical, the pluri- 
 valve, and the single blade. The cylindrical speculum, as 
 repri^sented by P^erguson's, once so popular, is now seldom 
 used, as the exposure is too limited and the space within 
 it too cramped. 
 
 The hiiHihu' speculum consists of two blades, joined at 
 one end, and looks anil opens something like the bill of a 
 duck, The lower blade is usually a little longer than the 
 upper one. It is introduced closed, either in the dorsal 
 
 iiiji^ 
 
EXAMINATION IN GENERAL. 
 
 79 
 
 Fic. i8.— Highee's Bivalve Speculum. 
 
 or Sims' position, niid is then expftndod by a screw or 
 lever. As the bla(U^s are expandcnl, the cervix settles 
 down on th(^ lower or posterior blade and thus comeB 
 into view. There are several 
 varieties, of which Cusco's, 
 Brewer's, and Higbee's form 
 fair samples. It is a very 
 satisfactory instriiment, botli 
 for inspection and treatnuuit, 
 and can be used witliout an 
 assistant. The tri-valve (Nel- 
 son's or Mott's) has two narrow blades, in place of the 
 anterior blade of the bi-valve. 
 
 Thi^ sin<j;le blade, or Sims' speculum or retractor, is 
 practically a Hatti'ned blade, made somewhat concave on the 
 vaginal surface, jind to which a slender liaiidle is attached. 
 For convenience, two blades of different sizes, one at each 
 end, an^ attached to the handle. When inserted it shows 
 the uterus and the anterior wall of the vagina in their 
 normal position and relations, its object biung to pull 
 
 back the p(>rin(ml body 
 and the posterior vaginal 
 wall. Besides this ad- 
 vantage, it readily per- 
 mits of treatment, and is 
 the sijeculum chiefly used 
 for opc^rations upon the 
 uterus and vagina. If 
 the cervix does not readily 
 come into view, the failure 
 
 Fig. ro.— Sims' Speculum. • . j. -i. i • i 
 
 ^ IS owing to its being ob- 
 
 scured by the anterior vaginal wall. To overcome this 
 difficulty, a flat blade, shaped like a spatula, or fenestrated, 
 and called a dcprcsso)', is made use of. To overcom(> the 
 necessity for having an assistant when using Sims' 
 speculum, many ingenious modiflcations nave been do- 
 
80 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 vised to make it self-retnining, but in every case their 
 application is troublesome and often unsatisfactory. 
 
 The uterine sound is an instrument made of a more or 
 less flexible metal, usually copper, with a slightly bulbous 
 extremity, and at a distance of two and one-lialf inches 
 from the extremity, is another bulb, indicating the length 
 of the normal uterus. It should first be bent to correspond 
 with the supposed curve of the canal, as found by bimanual 
 examination. When introduced, it indicates the longtli 
 and direction of the uterine cavity, and its relation to any 
 mass pn^ssing into or occupying that space. The mobility 
 of the body of the uterus may be determined also, as well 
 as the relation which it bears to a tumor or other ma.ss 
 
 -ill- 
 
 c\JtKTZo 
 
 Fig 2o. — Simpson's Sound. 
 
 adjacent to it. In is a very useful and, when properly 
 used, harmless instrument, but in handling it, it must 
 never be forgotten that it is cajjable of perforating the 
 uterine wall, and that it is being introduced into a cavity 
 from which absorption easily takes place. In its intro- 
 duction much difficulty is often experienced by the point 
 catching in the folds of mucous membrane in the cervix, 
 or by the opposition made by flexion. The difficulty may 
 be overcome by embedding the curved point of a tenaculum 
 in the tissues of the anterior lip and making counter- 
 traction, the effect of which will be to straighten out the 
 canal. 
 
 The pvohe is a much thinner and very flexible rod 
 used exclusively for exploring the inside of the uterine 
 cavity. 
 
 Uterine dressinp forrepF., of which a great variety 
 have been devised, are invaluable for wiping out the 
 
EXAMINATION IN GENERAL. 
 
 81 
 
 cervical mucous while mnkinpf inspection, for disinfecting 
 the vnginnl foniices, and for carrying medicated material 
 to the intended point of application. 
 
 Bozem.in's Pressing Forceps. 
 
 The vuhcllurn is a pair of forceps, each blade of which 
 ends in a double hook. It is used for seizing and pulling 
 
 Fig 22. — Viilsellum Forceps. 
 
 tissue, and is thus useful in steadying the uterus, while 
 introducing the sound or dilating the cervical canal. 
 
 Examination of the interior of the uterus. When 
 bimanual and speculum examinations make it evident that 
 the disease is seated within the uterus, an exi)loration of 
 its interior is essential. Usually the cervical canal presents 
 an effectual barrier to exploratioTi, eithe. by fin,»er or 
 instrument, and some method of dilatation must therefore 
 be used. This may be done slowlij by means of tents, or 
 rdpidly by graduated dilators or dilatating forceps. 
 
 Gradual dilatation, by means of tents, has now fallen 
 into complete disuse, except in isolated cases. From the 
 fact that it is impossible to render them aseptic and from 
 the necessity for the use of two or three to obtain sufficient 
 dilatation, their use exposes the patient to great danger. 
 For diagnostic puri)oses and as part of treatment, dilatation 
 
82 
 
 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 ia bost nofioniplisluHl mpidly by instruiiKMits. For tlio 
 lower (lejijrcc'H of (lilatnti(jn. Hunks' luinl riibb(^r or Hti^el 
 
 Krci. 23. — Hanks' ililators. 
 
 dilators, which como in .1 set of six, 
 embracing twolvo numbers, are very 
 serviceable. Commencing witli the 
 largest that will enter the canal, they 
 are passed in, one after another, until 
 the r(H|uired degiH^e of dilatation has 
 bt^en re( quired. For a higher degree 
 of dilatation, som(^ of tlu> steel 
 branched dilators may be used. A 
 very satisfactory instrument, perhaps 
 the best, is Goodell's modification of 
 Ellinger's, but being rather thick in 
 the blades, it niay be: found imposs- 
 ible to insert them when the cervical 
 canal is small, lender such circum- 
 stances it is best to commence with 
 a pair of lighter blades, such as that known as Wylic^'s. 
 After insertion, the handles are to be gradually compressed 
 and, as the parts yield to firm, slow pressure, what is 
 gained may be held by the screw or ratchet. The use of 
 this instrument, as well as of the graduated dilators, will 
 be facilitated if the cervix be steadied with a vulsellum. 
 
 Fi<;. 24. Gooilell's Di'ntor. 
 
EXAMINATION IN GENERAL. 
 
 8;{ 
 
 Th<' cuvi'ttc is nil instrument used for scraping ott' or 
 romoving pntliologicnl or otlu^r structureH from the inside 
 of the uterus. Althougli mostly used as a theraixnitic 
 agent, 8om(>times it is used to secure a specimen for gross 
 or microscopical examination. Tlic^re are two varieties in 
 use, one sharp and stitt', the other dull and somewhat 
 flexible. 
 
 From the frequent association of urirary symi)toms 
 with uterine diseas(>s, the best nu'thods for examining the 
 urethra and bladder should b(^ known to all [)ractitioners. 
 Some knowlcnlge of the condition of tlu' lower part of the 
 urethra may bt^ gained by inspection, some bladder and 
 urethral affections may be recognised by examination with 
 the linger, but for the deti^rmination of the exact condition 
 of the lining nnunbrane of th(> urethra, an endoscope is 
 
 Fii;s. 25, 26, 27. — Skene's Endoscope. 
 
 necessary. By inserting to its full length a simple tube, 
 sirailar to an ear speculum, the field being illuminated 
 with a head mirror, the whole urethra may be fairly well 
 inspected as the tube is being withdrawn. The most 
 satisfactory urethral endoscope is that known as Skene's. 
 By means of it, not only the neck of the bladder and 
 urethra may be inspected, but applications by means of 
 cotton or a spray may be made to any part of the canal. 
 The bladder can be explored digitally by first gradually 
 
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 MEDICAL AND SURGICAL GYNJIOOLOGY. 
 
 dilating tlie urethrn with Simon'R instruments until the 
 largest has been passed, after which the finger can usually 
 be inserted into the bladder. 
 
 Dr. Howard A. Kelly has extended and simplified the 
 technique of the examination of the bladder and ureters, 
 which permits of direct visual inspection of the female 
 
 Kio. 28.--noul>le Uretlir.-il Dilator. 
 
 bladd(^r and ureteral orifices, and which renders it possible 
 to complete the catheterization of both ureters within a few 
 minutes after the introduction of the specidum. The 
 following instruments are required: A urethral dilator; a 
 series of specula with obturators; a head mirror with some 
 form of artificial light; a im'ir of delicate mouse-toothed 
 forceps; an evacuator for withdrawing residual urine; a 
 
 Figs. 29, 30. — Speculum .nnrl Obturator {% natural size). 
 
 ureteral searcher, and a ureteral catheter. The hips are 
 somewhat elevated, and, after the necessary degree of 
 dilatation, a proper sized speculum is introduced and the 
 obturator withdrawn. By means of reflected light from 
 the head mirror, it is possible to examine fully the interior 
 
EXAMINATION IN GENERAL. 
 
 85 
 
 of tho bladder. Rosidunl urino obstructiiif? tlu' view may 
 be removed witli the evacuator, or, if very small in 
 amount, by little balls of absorbent (cotton held in tlu' 
 mouse-toothed foreeps. After a litth> prac^tiee the sites of 
 the urethral oritiees can be located. Dr. Kelly su^^m'sts 
 the following valuable aid for locatinjj: them: "A point is 
 marked on 'he cystoscopi^ at a distantn^ of five and one- 
 half centimetres from the vesical end, and from the jMnnt 
 
 Fig. 31. — Cystoscopic examination of bladder and direct catheterization ot ureters. 
 
 two diverging lines are draw toward the handle, with an 
 angle of sixty degrees between them. The speculum is 
 introduced up to the point of the V and turned to the 
 right or left, until one side of the V is in a line with the 
 axis of the body. By elevating the endoscope until it 
 touches the floor of the bladder, the ureteral orifices will 
 nearly always be within the area covered by the orifice of 
 the speculum." 
 
86 MEDICAL ANU SUIUJICAL OYN. ECOLOGY. 
 
 Tho RonroluT in itoxt omploytMl, nnd if what, is scmmi is 
 ronlly the oritici', it will at oiico pass ri'adily into it. Tho 
 ureteral catheter may then be subHtituted for the searcher 
 and the iirine coUected, as it passes from t\w kidney. 
 
 Examination of the abdomen. In a certain number 
 of cases inspection of the abdomen is important. The 
 practiced eyo can distinj^uish the pointed prominence 
 caused by a tumor or pregnancy, and the Hat enhxr^e- 
 ment. owin>^ to the presence of ascites or supi'r-abun(hint 
 adipose tissue; and vdien present, pigmentation, strije 
 albicantes, and a protruded navel are readily observed. 
 By paljAtion, the practised touch will show tho size, con- 
 sistency, and relations of a tumor, its mobility, and its 
 smoothness or irregularities. 
 
 FcrcHSsioii permits of defining, with greater accuracy, 
 the height to which a tumor rises, and the extent and 
 mobility of the area of dullness. 
 
 Auscultdiiou is of value onl^ in the differential 
 diagnosis of pregnancy from other varieties of abdominal 
 tumor. 
 
 CHAPTER VIII. 
 GYNECOLOGICAL THERAPEUTICS. 
 
 To be successful in the treatnxent of diseases of 
 women, pelvic disorders are not to be looked upon as 
 isolated conditions, but must be viewed, in a large number 
 of cases, as arising out of an existing or pre-existing con- 
 stitutional state, or faulty regime of the patient. Thus 
 the circulation and the digestive and other imijortant 
 systems may influence or be influenced, by the pelvic 
 organs, and when deciding upon a line of treatment, the 
 general condition of the patient must never be lost 
 sight of. 
 
GYNAECOLOGICAL THERAPEUTICS. 87 
 
 Cicucvdl hi/jjicnc is nn importntit fnctor. Tlio mind 
 Hhould be ns far as possible froo from anxiety hikI strain, 
 yet at the same time actively (employed in some healthy, 
 intelle(^tual pursuit, and the body stimulated by exercise 
 suited to taste and circumstances. The strictest attention 
 should bo paid to the menstrual period, and every girl 
 should be taught how to take care of herself during the 
 performance of that important function. Regularity in 
 the action of the bowels and attention to their daily 
 evacuation, regular attention to the calls for micturition, 
 attention to the functions of the skin, and regularity of 
 meals and sleep, both as regards time and duration, are 
 also of great importance. The clothing, while not being 
 too heavy, should be of such texture and material, and so 
 distributed, as to keep every part of the body equally 
 warm. Exercise in some form or other is often bene- 
 ficial, but should never be excessive. What the particular 
 form of exercise shall be, must dejjend upon the taste or 
 occupation of the individual. Each condition with which 
 we have to deal will suggest points ai)plicable to it. 
 
 In the i)elvis, as elsewhere, pain and disordered 
 functions are indications for rest, and in no department of 
 medicine is rest more essential than in this. In the 
 majority of patients, their sufferings are due to fulness of 
 the vessels within the pelvis, and to overcome this r>»st in 
 the recumbent position is absolutely necessary. But rest 
 to be complete must be not only local and general, but 
 physiological as well. 
 
 A very large number of gymecological jjatients suffer 
 from aniBmia, and often from anorexia. Careful attention 
 must be given to the diet, and when so prescribing, 
 precise orders should be given in regard to the time, 
 the quality and quantity of meals, as well as to a proper 
 variety. 
 
 Drugs. Pi(r<j(ifir<'s In no class of diseases are 
 purgatives more useful. Constipation, acting locally, maj 
 
88 MEUKJAL AND SURGICAL GYNAECOLOGY. 
 
 soriously displnce tlie pelvic, viscera, or by pressure pro- 
 mote congv^stioii nnd discomfort. In many cases of 
 chronic pelvic disefxse, a course of jjurgatives, such as 
 sulphate of magnesia, cascara sagrada, aloes, with an 
 occasional dose of calomel, will greatly relieve the patient, 
 and where there if. systemic portal congestion, morning 
 draughts cf Carlsbad salts, or Hunyadi Janos, Apenta, or 
 Franz Josef mineral waters will, by their mild laxative 
 action, afford much relief In acute pelvic inflammation, 
 saline purgatives aie highly beneficial. Enemata of warm 
 water, and rectal injections of glycerine, are useful 
 adjuncts or alternatives. 
 
 Tonics. Nearly all kinds may find a place in the 
 treatment of pelvic disease. Unless contra-indicated, iron, 
 in some form, is one of the most active, and when ad- 
 ministered gives the best results when combined with a 
 purgative. Arsenic is valuable when lucorrhcea is present 
 in amemic girls with a chronic catarrh of the vagina or 
 cervix. Combined with iron, it acts well in ansemia and 
 chlorosis with scanty catamenia. Quinine, aside from its 
 specific effect, has a special tonic action on the uterine 
 muscles, and is therefore useful as an adjunct. 
 
 Seddtires, especially the stronger ones, should be 
 administered with great caution, for often the condition 
 for which they are j^rescribed is a recurrent one, and the 
 repeated administration may lead to the abuse of these 
 agents. 
 
 Special Gynaecological Drugs. Ergot is used for two 
 main purposes, to encourage uterine contraction and to 
 lessen uterine hemorrhage. On this account, it is ad- 
 ministered for passive uterine hemorrhage, in uterine 
 fibroids, fungous endometritis, subinvolution, and in 
 uterine congestion. In chronic hemorrhage, or when it is 
 given for lengthened periods, it should be combined with 
 acids and purgatives. 
 
GYN.ECOLOGKiAL THERAPEUTICS. 81) 
 
 (losi^/ipiiim, in the form of fluid extract, or decoction 
 freshly prepared, is an ommenap-o^ue and partvirient. It 
 has a tonic influence on the uteruB, relieves pain, and 
 often seems to act better than ergot in arresting imssive 
 hemorrhage. 
 
 Hi/drastis Camidrnsts, in the form of fluid extract or 
 tincture, has a decided ecbolic action and, if taken regu- 
 larly, will check chronic hemorrhage, and besides has a 
 decidedly sedative effect. 
 
 HiinKimclis has been accorded a high place i:i the 
 scale of uterine haemostatics wliere passive engorgement 
 exists. 
 
 CcDinabis ImJica, in the form of extract, is extremely 
 useful in cases of menorraghia with pain, in dysmenorrhoja, 
 and in some cases of fibroids. It is apt to affect som<* 
 women i)eculiarly, and at first must be given cautiously 
 and in small doses. 
 
 Viburnum pr'nnifo] in m is an anti-spasmodic, relieving 
 painful contraction of both voluntary and involuntary 
 muscles and is, therefore, useful to prevent abortion in 
 catses where uterine contraction precedes the death of the 
 foetus. A large group of anti-spasmodics and sedatives 
 may be used for the relief of pelvic pain, among which 
 may be mentioned some of the coal tar derivatives, such 
 as phcnfivcfine. 
 
 The Bromiih'fi allay th.i pain and restlessness due to 
 increased local tension, as in congestion of the ovary. 
 They tend to lessen hemorrhage of a passive type, and are 
 excellent remedies to anticipate the headache and nausea 
 which precede dysmenorrluwa. 
 
 Chloride of Ammoninm acts upon the portal system and 
 thus tends to relieve pelvic congestion. It is useful in 
 simple congestion, subinvolution aiul chronic metritis. 
 
 Chloride of Colrinni, given thrice daily, in doses of ten 
 to twenty grains, often acts like a charm in some cases of 
 menorrhagia. 
 
<.K) MEDICAL ANO SURdlCAL (iYN.ECOLOCJY. 
 
 Jicsol rents nro oftou cnlli'd for in chronic inHuniniation, 
 to prom(>tc absorption of lon^ stmuling iiitiaininntory 
 exudation. The most important of those arc, iodine in 
 the form of iodide of potassium, sodium or ammonium; 
 mercury iu tlu^ form of bichUiride, and gold in the form 
 of chh)ri(U« of sodium and gold. 
 
 The local therapeutic effects to be derived from the 
 application of Itnif and cold are well known. 
 
 1. E.riernal aj>pli('<itioii. Cold, locally applied, is a 
 depressant, checking the vital action and diminisliing the 
 bh)od supply, and hence is useful in hypenvMnia or con- 
 gestion of the pelvic organs. It may be applitnl in the 
 form of ice-bags, or by means of a Leiter coil. Hc<d, in 
 the form of hot baths, is mainly sedative, relaxing the 
 skin and its glands, dilating the i)eripheral vessels, and 
 thus relieving congestions of internal viscera. It is 
 therefore useful in congestive dysmenorrhoia, and, by its 
 power of relieving muscular spasm, is serviceable in 
 spasmodic dysm(>norrho>a and in cases of uterine, tubal 
 and other pelvic and abdominal colics. Hot foot and sitz 
 h(itlt)'- act somewhat similarly and are particularly useful 
 in relieving pelvic congestion produced by sudden arrest 
 of the cntamenia. Mustord, added to such baths, increases 
 their effects. Pout f ices and fonundfitioiis. both as to their 
 utility and actio'i, may be considered as local baths. If a 
 sedative effect is required, opium, in the form of laudanum, 
 may be added; if a stimulating effect is required, turpen- 
 tine. Heat may also be aj^plied, locally, by means of 
 hot Wider cans and rubber bags. 
 
 2. Iideritfd ((pjdiecdion. Hot water has a far more 
 extensive field of usefulness in the pathology of women's 
 diseases than any one agent. Hot water may be made to 
 enter the vagina while in a bath, by means of a speculum, 
 but the usual method employed is by means of a dourlie 
 (ippandns. In all cases, the flow into the vagina should 
 be continuous, hence, for the purpose, an elevated ci-uJie- 
 
OYN.Et'OLOCilCAL THliUAl'EUTICS. 91 
 
 (•nil. or sonip syplion nrran^tMinMit, is bi'ttcr tlum the 
 ordiiuiry luviul-bulb syriti^o. The vfiKin'il nozzlo should 
 bo of somo smooth mntorial, easily innde nscptic, and, 
 during administration, tin* patient should lie flat on the 
 back witli the pelvis raised on a Ixul-lxitli. For merely 
 cleansing tlK> vagina, tepid water will suffice, but its eliVit 
 may be increased by adding a drnm of bicarbonate of 
 soda, borax, or boracic acid, to the pint. For the relief of 
 congestion, water, at a temperature of 100° to 105° F. is 
 indicated, but for the arrest of hemorrhage, a higher 
 temperature is required. By the addition of medicinal 
 agents the douche can be rendered antiseptic, anodyne, 
 astringent, or sedative. Cold water applied to the vagina 
 is unsafe and should not be made use of. 
 
 Counter irritation to the skin may be applied in a 
 variety of waj'^s by such drugs as mu.stard, turpentine, 
 iodine, croton oil, or cantharides. 
 
 Applications to the vagina may be made in varibus 
 ways. Donrlicsi are a convenient way of applying medi- 
 caments. If for antiseptic purposes, bichlori.le of 
 nuTcury, 1 to 4000 to 1 to 2000, and carbolic acid 1 to 200, 
 may be used, but their prolonged or frequent use is to bo 
 avoided, owing to the dangers from absorption. Weak 
 solutions of potassium permanganate and of sulplio- 
 carbolate of zinc may also be used, but r.re not so 
 effectual. If required for astringent purposes, plumbi 
 acetate, zinc sulphate, alum, and tannin are the best. 
 
 Mcdicdtcd ix'SSfirics may be used for tlieir local effect, 
 as well as for their remote, and when for the latter, double 
 the usual dose should be administered. 
 
 Pessaries of glycerine, combined witli gelatine, will 
 relieve vaginal congestion and encourage se(;retion. If so 
 desired, drugs may be added to such pessaries, and it is in 
 this form that ichthyol has its most useful sedative and 
 absorbent api)lication. particularly in subinvolution asso- 
 ciated with endocervicitis and granular erosion. The 
 
\)2 MEDICAL AND SURC.ICAL OYN.ECOLOOY. 
 
 dnij;H nu)st oftcMi usimI nn scdativcH nro ctx^nino. niori)1jin, 
 extract of lu'lladoiin!! and extract of henbane; as astrin- 
 j^entH. alum and tannin, and. when so ein[)loyed, may be 
 combined with cocno-butter or gelatim^ For this purpose, 
 gauze, too, saturated with various int^redients, is readily 
 ap[)lie(l. 
 
 Tdinpons macU' from wool or absorbent cotton, roHed 
 and tied in sizes most convenient for the work recpiired 
 of them, may be used to advantage as conveyers of 
 medicinal agents, such as boric acid, ichthyol in glycerine, 
 lysol, aristol, balsam of Peru, aciueous solutions of alum, 
 and other agents; and, when so m(>(licated, serve a good 
 purpose for stimulating, sedative, or astringent apjjlica- 
 tions. They are also used as temporary means of Hujjnnrt. 
 for exerting pressure, and to soften and stretch organized 
 bands within the pelvis. Tampons may be also employed 
 to plug or to tightly pack the vagina for the arrest of 
 hemorrhage and to maintain an aseptic condition. 
 
 Direct application of drugs may be made, through a 
 speculum, to any affected area of tlu^ vagina by means of 
 a pledget of absorbent cotton held in the jaws of a pair of 
 uterine dressing forceps. Nitrate of silver, in various 
 strengths, solutions of sulphate of copj^er, tincture of 
 iodine, carbolic acid, iodized pheno?. litiuor ferri perch- 
 loride, ichthoyl, glycerite of tannin and such like, are all 
 useful therapeutics agents in appropriate cases. 
 
 Applications to the uterus. The same drugs used for 
 the vagina may also be used for the vaginal portion of the 
 uterus, and are to be applied in the same way. To npi)ly 
 substances to the cervical canal, it must be exposed, and 
 by the aid of a Burrage's sijeculum and cotton holder, 
 the mendicament is directly applied. Until very recently, 
 it was the practice to make applications of many of the 
 remedies mentioned to the cavity of the uterus, but it has 
 now fallen into disuse, and in cases, where previously 
 employed, the practice of to-day is thorough curettage and 
 
GYNAECOLOGICAL THEKAPEUTICS. 
 
 93 
 
 cleniisiiig nnd drainiuj^ of tho canal. Wlioii that has boon 
 thoroughly douo, it is all that is nocosKary. 
 
 Intra-uterine injections nrc nuioh inoro ilangorous 
 than va^'iual. Largo utorino injootions of w> rni wator, 
 medioatod or othorwiHo, nmy bo usod for olon using nnd 
 disinfocting tho utorus, and for chocking lioniorrliago. If 
 tho corvix has boon thoroughly dilatod, a curved glass 
 
 CX: 
 
 Fig. .!2. — Burrage's Cervical .Speculum, a, tulie ; fi, handle ; r, movable cl.isp ; 
 ri •.mall tulie at right angles to main lulie ; ,•, smaller cervical tube to replace a ; 
 ./, ihmrator fitting the two tubes. 
 
 single current tube is proforable, but if tho cervical canal 
 is not so \s,'id'), a metal double-current utorino tube sliould 
 be used, such as Bosoman's, a Cusco's or other spocudum 
 having boon previously introduced, and while administer- 
 ing tho flow should bo carefully watxihed. 
 
 Vui. 33. — Intra-uterinc Douche. 
 
 Vesical injections are much used in the treatment of 
 diseases of the bladder. For large injc^ctions, a fountain 
 syringe with a hard or soft catlu^ter attached and a two- 
 way stop-cock whi(^h allows tho bladder to bo alternately 
 tilled and emptied, acts very well. Wluu\ simple irrigation 
 is required, Nott's doubh^ current catheter proves very 
 serviceable. A simple, yot very effectual vesical douche 
 may be made by attaching to one end of a rubber tube a 
 
94 
 
 MEDICAL AND SUUOICAL OYN^COLOUY. 
 
 fr 
 
 small funnel, or tho barrel of n lar^o ^lasH male syringe, 
 and to the other an ordinary glass oatlu^ter. Tlu^ tluid is 
 pour(uI into tlu^ reeeptaele, lu^ld at tlu^ nupiired distance 
 above the patient, and, when suftieitMit has I'ntered, the 
 rec(>ptaole is lowered, which permits the 
 fluid to be syphoned out. 
 
 Curetting. In the treatmiMit of 
 diseases of the uterus this minor opera- 
 tion is often demanded. It retiuires 
 the administration of an anaesthetic, 
 jdthough some can undergo the ordeal 
 without it. The cervical canal is first 
 dilattnl carefully with steel dilators to 
 such a size as will readily admit the 
 curette. The cavity of the uterus is 
 next fl\ished through a Burrnge's spec- 
 ulum, or by means of an intra-uterine 
 r^ douche, with a 1 to 2000 
 
 solution of bichloride. 
 
 Fig. 34.- 
 Tenacula 
 
 The cervix being grasped 
 
 with a vulsellum or ten- 
 aculum, to steady the 
 
 uterus, the sharp curette 
 
 is introduced and the 
 
 entire cavity carefully 
 
 scrap-id, the persisten 5e 
 and vigor with which this is done 
 being governed by the conditions 
 Ijre-sent. The antierior and pos- 
 terior walls, the lateral sulci where 
 these two come together, the fundus, and tlu^ recesses of 
 the cornua are scraped in turn. The cavity is next 
 irrigated with the warm bichloride solution, and dried 
 with a little cotton on a holdi>r. Should circumstance ? 
 demand it, the cavity may be touched over with carbolic 
 acid, tincture of iodine, or iodized jjlienol, after which it 
 
 Fk;. 35. — Wire- 
 loop Curettes. 
 
 Fig. 36. — Sharp 
 Curette. 
 
(lYN.ECOUKJIC'AL THEKAl'lirTIOS. 9B 
 
 Ih aj^ftiii to b(^ (Irit'd witli cotton. Tf (icemod adviHnblc, tlio 
 uterus nuiy be draint'd by the introduction of a Ktrip of 
 iodoform ^auzci, or it may be packed with the Hanm 
 material. Aa a rule, ^ood draiuag(> is all that is uocesHary 
 after thorough curettage. 
 
 Pelvic massage. Though massage, in its dit1"'erent 
 forms, enters into tlu^ treatmcMit of various femaU^ afVec- 
 tions, it is also valuable as a part of the giuieral care of 
 the body, both to increase the activity of the blood (uimuit 
 HO as to bring it mori^ fn^quently in contact with the oxygen 
 of the lungs, and to promote nutrition, by making the 
 muscles work out what elements they have alreatly taken 
 up, but have not utilized. By this means, the body at 
 largi> becomes more vigorous and robust, and thus will 
 respond more effectually to therapeutics and to the local 
 treiatment of the organs, the care of which are being 
 considered. A form of massage, known as pelvic massage, 
 has been elaborati'd and brought to bear upon the class 
 of ailments which usually prove most intractable, and for 
 the treatment of which the means at our commantl have 
 always been too few. This class of treatment has given 
 excellent results, when judiciously undertaken, in selected 
 cases, and when carried out with patience and with a clear 
 perception of its indications. It is applicable to a great 
 diversity of ailments, but it may be stated, in a general 
 way, that chronic; female affections, such as persistent 
 pain, constantly recurring congestion, displacements, de- 
 formities and fixation of organs, attributable to lack of 
 support or increased weight, peritoneal inflammations and 
 lymph deposits, are the ones which we may hope to benefit 
 most by this method. As opposi^d to this class, there are 
 also conditions entirely unsuited to such handling. Mas- 
 sage should never be attempted in any acute disease, nor 
 in any acute exacerbation of a pre-existing disease, nor in 
 the presence of pus tubes or pus in any part of the pelvis, 
 nor in cases of pregnancy, normal, or still less, abnormal 
 
96 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 or ectopic. The only exception is a retroverted uterus 
 before the third month. Tuberculosis of the peritoneum 
 is another contraindication, also ovarian cystoma, cysts of 
 the broad ligaments, fibroids and malignant growths any- 
 where within tln^ pelvis. 
 
 Massage, in the diseases specified, consists briefly in 
 kneading the pelvic masses, applying friction to them 
 to cause their absorption, and in moving the uterus in 
 different directions to stretch and free its adhesions. The 
 manipulation is carried out with one hand pressing 
 through the abdominal wall and with one or two fingers 
 of the second hand in the vagina. The vaginal fingers 
 are used mostly for lifting up and fixing the uterus or 
 pelvic masses, the manipulation being carried on, for the 
 most part, by the abdominal hand. 
 
 CHAPTER IX. 
 
 POST-OPERATIVE TREATMENT. 
 
 There are certain well-defined principles which may 
 be followed in conducting the after-treatment of a patient 
 upon whom an abdominal section has been performed, 
 the observance of which is of the greatest importance, and 
 the neglect of which may be attended with serious results. 
 After operation the patient is to be remov'ed to lu>-r bed, 
 previously made warm, and hot-water bottles carefully 
 placed on each side. One-thirty-second of a grain of 
 strychnine is at once given, and repeated every four hours 
 for the first twenty-four hours; every six hours for the 
 next twenty-four hours, and after that, only if required. 
 It is (extremely difiieult to lay down definite rules regarding 
 food and drink, as patients respond differently under the 
 same management, and the greatest ingiuiuity is often 
 required. During the first twelve hours it will be found 
 
POST-OPERATIVE TREATMENT. 07 
 
 preferable to give nothing except small quantities of toast 
 water, or warm water, from one to two teaspoonsful every 
 ten or fifteen minutes; or ten to fifteen drops of sherry m 
 two or three teaspoonsful of soda water, testing the ability 
 of the stomach to retain and absorb it. This frequency 
 of administratioTi is not only tolerated, but is very com- 
 forting to the patient, relieving the thirst and diminishing 
 vomiting as well, when present. Ice, as a rule, while 
 grateful to the mouth of the patient, is not as well borne 
 as warm water, and the patient is never satisfied; besides, 
 the injection into the stomach of cold wati^r is apt to 
 cause nausea. The distressing thirst, so often complained 
 of after operation, may be relieved by frequent injections, 
 into the rectum, of half a pint of normal salt solution, and 
 with some it is the practice to inject high up into the 
 sigmoid flexure a quart of this solution, before the patient 
 leaves the operating table. After the first twelve hours 
 small quantities of chicken broth or beef tea, half an 
 ounce every half hour, may be allowed, the time between 
 administrations being extended as the amount given is 
 increased. Albumen water, into which the juice of a ripe 
 orange has been S(iueezed, is often well tolerated and very 
 comforting. Milk, as n rule, is not a good substance to 
 give by the mouth. It is not easily digested in the 
 stomach, and the thick curds formed are either ejected, or 
 act as an irritant in the intestinal canal. Peptonized 
 milk has not this objection, and, as a rule, is well retained, 
 but many patients object to the peculiar tast(^ Weak 
 oyster-broth has often been retained with much satisfaction, 
 when other nutriment has been rejected. Small (piantities 
 of ginger ale sometimes act as a sedative to the stomach, 
 relieve thirst and flatulence, and are often eagerly demand- 
 ed by the patient. At the end of the third day the 
 dietary may be increased and administered every two 
 hours. Milk may now be given, combined with lime- 
 water. Such articles of diet as gruel, light thin porridge, 
 
98 MEI)I(!AL AND SURftlCAL OYN^OOLOGY. 
 
 custards, rico, sago, tapioca, thin strips of bread and 
 butter and poached eggs may be gradually added to the 
 list until the eighth or ninth day, when some solids may 
 be introduced. 
 
 The arms, legs, and chest may be sponged with warm 
 alcohol, or with soaj) and water, and subsequently con- 
 valescence is promoted by frequent sponging and by rub- 
 bing the body with alcohol. If there is much restlessness, 
 or if the patient suffers severe pain, a small hypodermatic 
 of morphia, one-sixth to one-quarter of a grain, may be 
 administered, but the routine employment of it is to be 
 condemned. It is much better to encourage the patients 
 to control themselves and to endeavor to endure the pain. 
 It delays healing, checks secretion and elimination, as 
 well as the peristaltic action of the bowels, functions so 
 much required at this critical time, besides it places the 
 patient in such a . mood as to be an unsafe monitor of 
 untoward or alarming symptoms. 
 
 Purgatives. It is imperative to obtain a movement of 
 the bowels at as early a period as possible, and it is 
 astonishing to note the great change for the better which 
 takes place when this has been satisfactorily accomplished. 
 If, at the end of forty-eight hours, a good satisfactory 
 movement of the bowels has been obtained, and the pulse 
 below one hundred, the patient is convalescent. If, on 
 the other hand, the bowels remain unmoved, in spite of 
 efforts to open them, and tympany appears, with rising 
 pulse, it is a serious matter. On the second day after 
 operation, an effort may be made to move the bowels, some 
 administering grain doses of calomel every hour until five 
 doses have been given; others recommend teaspoonful 
 doses oi Rochelle or Epsom salts every two hours until 
 three doses have been given. Medicines by tlie mouth 
 for this purp';.->e are, however, often contra-indicated, 
 causing nausea or the upsetting of the stomach. The 
 most satisfactory method consists in the administration, 
 
POST-OPEKATIVE TREATMENT. IH) 
 
 on the second day, of nn enema of warm water and soap- 
 suds, introduced as high up as possible, by means of a 
 rectal tube or large catheter. If the enema is not effectual 
 it may be repeatt d once or twice at intervals of two or 
 three hours. Fl( tulcnce, or accumulation of flatus in the 
 bowels, is often a distressing symptom, but generally may 
 be effectually relieved by adding spirits of turpentine to 
 the enema, aided by light massage over the region of 
 the colon. A few drops of tincture of capsicum or of 
 essence of peppermint, in water, will often giv(^ material 
 relief. Tlu^ patient should be catheter i zed shortly after 
 operation, and, if necessary, every six hours afterwards, 
 but she is to be encouraged to attempt to void the urine 
 voluntarily, provided it can be done without much 
 straining. Nearly every patient is restless and suffers 
 more or less pain, which may be relieved by some slight 
 change in position, or by putting a soft pad under the 
 head and shoulders, or under the bends of the knees. 
 
 Shock following prolonged, or any operation, can best 
 be treated by kc^eping up the dry heat to the body and by 
 hypodermatics of whiskey or b-andy and strychnine. The 
 routine practice of injections ot strychnine, commenced at 
 once after operation, will often prevent the appearance of 
 the symptoms of shock. 
 
 Hemorrhage. Indications of collapse, with a falling 
 temperature and rapidly rising pulsi^, points to this grave 
 danger, and no time must be lost in re-opening the wound 
 and se(Oving for the mischief, and stimulating treatment 
 afterwards pursutnl by every effort known, (rreat benefit 
 will be derived from rectal injections of normal salt solution, 
 but more particularly from injections of the same solution 
 into the pectoral region by means of a small aspirating 
 lUHHlle attached to an ordinary enema syringe. Large 
 quantities can thus be injected, if rigidly persisted in. 
 The vomiting, due to the anaesthesia, should be over at the 
 end of eighteen or twenty-four hours, but sometimes it 
 
100 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 persists longer niid becomt's n most troublesome symptom. 
 When vomiting continues after the third day, especially 
 wluni the fluid is expelled without much apparent force, 
 peritonitis is to be feared, lender the circumstances 
 nothing is to be given by the mouth whatever, but rectal 
 enema of peptonized milk or beef tea and the white of egg 
 may be given instead. To allay thirst and dryness of the 
 mouth it may be frequently rinsed out with cold water. 
 
 As a rule the patient should not be allowed to sit up in 
 bed until the eighteenth day. At the end of the third 
 week she may be allowed to get out of bed, and at the end 
 of the fourth week, allowed to walk, but before doing so 
 she should be furnished with an abdominal bandage, to 
 prevent any opening of the incision, to be subsequently 
 followed by a hernia. 
 
 The after-treatment of plastic operations for the repair 
 of the perineum or cervix resolves itself into rest and 
 cleanliness. The patient should remain in bed for two 
 weeks, and after that should take another week in getting 
 up and about. If a gauze tampon has been introduced 
 into the vagina, it slioul 1 bo removed after forty-eight 
 hours, and a warm sterile \' iter douche given daily. 
 
 Two aloin, strychnine an l)elladonna granules may bo 
 administered on the second evening after operation, 
 followed by a rectal enema in the morning. 
 
 CHAPTER X. 
 
 GYN/ECOLOGICAL APPLICATION OF ELECTRIC 
 
 CURRENTS. 
 
 But two currents may be said to be in use in gynre- 
 cologieal therapeutics; the <i<ilr(Uii(' or direct current, and 
 the Faradic, induced or iutcrrupted current. 
 
 The articles considered necessary for the application 
 of the galvanic current are, a battery, composed of from 
 
APPLICATION OF ELECTUIC CURRENTS. 101 
 
 forty-tivo to Bovonty Loolnnche coIIh. set up " in scTios," or 
 tin- supply terminals of nn inenndesccnt electric li^lit 
 current. A riirrcid controller, such us the Mnssey, or 
 some reliable rhcosiot, to regulate or turn off or on the 
 current; a (jdlvdnometcr, indicating from 1 to 500 milliam- 
 lieres; rhcophorcs or flexible metallic cords, for conducti ng 
 the current; various forms of eh'cirodvs for its application, 
 and a romninfotor or pole chamicr. Instead of such a 
 bulky battery, many will doubtless prefer a portable one, 
 excellent varieties of which are to be fo'ind in most 
 instrument shops. Electrodes, when in use, are distin- 
 guished by the terms "positive" (anode) and "negative" 
 (cathode), the former receiving its name from being 
 attached to th(> first carbon, and the latter from its being 
 attached to the last zinc of the battery. They are also 
 distinguished by the terms, " internal " and " external,' 
 according to the locality to which they are applied. 
 
 Various forms of intra-uterine electrodes are in use. 
 They are made of platinum, occasionally of copper or zinc, 
 shaped like a Simpson's sound, c 
 
 and so insulated as to expose r^—^ f\ 
 
 orly a small portion of the £_ * 
 
 distal end. The external, cutan- 
 eous, or dispersing electrode is 
 composed of a large, flat, con- 
 ducting surface. There are 
 several varieties. Apostoli uses 
 moistened sculptor's clay; 
 Engelman, a flexible plate of ,. ^ , , 
 
 , . '' "'• 37 -iM.irlin s cutaneous electrode. 
 
 lead, six by seven inches and 
 
 Martin, a large concave plate, covered with a membrane 
 and capable of containing warm water. This electrode is 
 usually applied to the abdomen, sometimes to the back. 
 By using large and wet electrodes, we chiefly get the 
 interpolar effect, which is that of electrolysis. By using 
 small and dry electrodes, we chiefly obtain the polar effect, 
 
102 MEDICAL ANU SUIUUCAL GYNAECOLOGY. 
 
 which, whi^ii the cunoiit is strong enough, bocomos 
 chemical cnuterizntion. 
 
 By combining largo wot oloctroch'H on the skin with 
 small dry oloctrodos in the uterus, burning of the skin is 
 avoided and chemical cauterization of the uterus obtained. 
 The two poles of the battery have ditFerent physical and 
 physiological effects. The positive pole attracts acids, 
 while alkalies collect ut the negative; tli oschai" 
 produced by the positive pole is dry, that by the nega- 
 tive is softer and larger and allows the galvanic? current 
 to penetrate througli it; the negative pole has a 
 stimulating effect and will draw blood to the parts, the 
 positive i)ole has a depressing, anti-congestive powiT, and 
 will disixd it; the negative pole causes pain, the positive 
 allays it; the positive pole has an escharotic drying 
 effect, the negative a softening, liquefying effect. 
 
 The Faradic current is produced by loading the 
 electricity, generated in two or three Leclanche cells, 
 through a short coil of coarse insulated copper wire, called 
 the primary coil, in such a way that the current is broken 
 and closed at short intervals. Outside the primary coil 
 is another, called the secondary coil, which consists of a 
 much longer and finer one of insulated copper wire. The 
 current passing througli the primary coil is called the 
 primary current, and that induced in the secondary coil, 
 by means of the primary current, is called the secondary 
 current. Both currents produce muscular contraction, 
 but the secondary, producing the effect in a higher degree, 
 is more generally used. With this current, in addition to 
 the electrodes already mentioned, bipolar intra-uterine 
 and vaginal electrodes are used by which the effects of the 
 current are centralized. 
 
 Practical application. Amenorrhooa of the functional 
 type is one of the aft'ections in which we may hope for the 
 greatest amount of good. Both the galvanic and the 
 Faradic may be used alternately in this condition. Mild 
 
APPLICATION OF ELECTRIC CUKKENTS. 
 
 lo;} 
 
 gnlvniiio currents nv t best, from fifteen to rwenty nuUiani- 
 peres. Tlie positive jjole is to be placed over the abdomen 
 by means of the large electrode, r.nd if a virgin, the 
 negative may l)e applied, by meaiiH of a smaller electrode, 
 over the perineum, or if she Las 
 borne chiLlron or is married, it 
 is to be placed in the uterine 
 cavity. For the application of 
 the Faradic current the bipolar 
 vaginal and intra-uterine elec- 
 trodes may be used alternately. 
 iSit-iior,,\,()ftli(' uterine candl, 
 such as congenital pin-hole os 
 externum, spasmodic contraction 
 of the internal os, without ap- 
 parent disease, stenosis due to 
 sharp flexion forward or back- 
 ward, are amenable to galvanic 
 treatment. The negative pole 
 is to be applied to the constricted 
 part and the large positive pole 
 to the abdomen for ten or iifteen 
 minutes, with a powe" of fifteen 
 to twenty milliamperes. 
 
 Galvanism is also useful for 
 almost every form of dijsmen- 
 ovrluva. Here the best results 
 
 will be attained by the introduction of the positive jwle 
 within the uterus, because most painful menstrual states 
 are attributable to congestion in that region. The mem- 
 branous form yields better to curettage, but if galvanism 
 is to be emi^loyed, the negative pole in the uterus gives 
 the best results. 
 
 In suhinvolntion, depending ujjon a low grade of in- 
 flammation of the uterine tissue, in which the uterus has 
 engorged vessels with inactive muscular structure and a 
 
 Fk;. 38. — Apostoli's Bi-polar Ulcrine and 
 Vaginal Kxcitors : i, small uterine ; 
 2, metlium uterine ", 3, large uterine ; 
 4, vaginal, used in the uterus after 
 confinement. 
 
104 MEDICAL AND SURGICAL GYNvECOLOUY. 
 
 cortaiii amount of lymph thrown out, couKi(h'rnl)U' UHsist- 
 ance may be obtaimnl from tho use of tho Faradic^ current; 
 one pole in contaet with the cervix^ the other over tho 
 ab'lominal or lumbar region. 
 
 In mihintJolufioH, in connection with injuries (luring 
 parturition, notably of the cervix, and in connection with 
 tubal and ovarian diseases and pelvic exudates, the gal- 
 vanic current, with t:ie negative pole within the uterus, 
 must be utilized. Fifty or sixty milliamperes of this cur- 
 rent, applied for fifteen or twi^nty minutes, twice a week, 
 will soon soften the uterus and render it capable of 
 absorbing, as well as promoting the absorption of patholo- 
 gical products of long standing. 
 
 EmIomHritis, In the simple catarrhal form, with 
 hypersecretion of the uterine follicles, and from frequent 
 repetition of which the uterus has become chronically 
 eidarged, the Faradic coil will cause the organ to regain 
 its tone, and its nutrition may be improved by frecjuent 
 and mild applications of the galvanic current, the positive 
 polo being intra-uterine. In the hemorrhagic, or fungous 
 form, recourse is to be had also to the positive galvanic 
 pole, seeking to bring it in contact with the entire 
 surface. 
 
 Fl<i>ifie <'.ifii(l(iti()ii. Good results often follow the adop- 
 tion of this treatment in old parametric and i)erimetric 
 exudates, but a careful diagnosis that pus is not present 
 somewhere, must be made, before proceeding to its use. 
 The positive ball electrode, covered with chamois or clay, 
 is to be placed within the vagina and the largo electrode 
 over the abdomen. Beginning at zero, the current is to be 
 worked up to forty or tifty milliamijeres, and continued at 
 that point for ten or fiteen minutes. The treatment is to 
 be repeated twice a week. 
 
 CdUirrluil S<ilj)lii</itis. The positive electrode is to bo 
 pushed uj) as far as possible into the uterine cornu and a 
 
APl'LKJATION OP ELECTRIvJ CUKUIiNTS. 105 
 
 morlornto ".ilvniiic riurront of twonty to thirty millinm- 
 peroK, for t 1 to fift(>(M) miiiutoH, tununl on. 
 
 In elm <• rotujcxtiou of flic onirif, without dcciih'd 
 (U'g(4uirntion, the poHitivo ball oUH!tro(le in to In* plmuMl in 
 the vajifina or rectum, as near as possible to the eiihirjjjcd 
 ovary, and a moderate curreni of ten to twenty inilliani- 
 per(>s. for ten minutes, applied. 
 
 Orai'ian (did pclric nciu'dhjia. There »ire eertaiu pains 
 in the region of the ovaries and deep within the pelvis 
 which are found difficult to associate with disease, but 
 which are more likely samples of reflex neuralgia. In such 
 cases electricity may be used to great advantage. First of 
 all, use bipolar faradization with the tine wire coil, 
 graduallv' increasing the strength, then changing to the 
 coarser wire coil, until the parts either become benumbed 
 or free from pain. 
 
 Uterine jibroids. Before attempting electrical treat- 
 ment in such cases, a positive diagnosis must be made of 
 their position, whether sub-peritoneal, intra-mural, or 
 sub-mucous, and of their quality, whether hard, or of the 
 soft, cedematous variety. 
 
 Snb-miirous pcdniicnldtcd Jihnu'ds will be benefited 
 by the treatmeni, only by being forced out of the uterus, 
 and care should be taken not to devote much attention to 
 sub-peritoneal fibroids. Of the different varieties, the 
 myo-fibromata are the ones for which the most good can 
 be accomplished. Next in order stand the pure fibromata, 
 but the durable effect, when once produced, will be the 
 most marked in the fibromata. The first variety will 
 require small amounts of galvanism frecjuently repeated, 
 the latter will call for high intensities and short 
 sittings. 
 
 The application of galvanism to soft (vdcnudous 
 tititiors should be avoided, as it often stimulates them to 
 new growth, or promotes a tendency to break down into 
 fluid spaces. 
 
1 1 
 I 
 
 ii 
 
 
 10() MEDICAL AND SURGICAL OYN.ECOLOOY. 
 
 Fi'hi'o-cijstic tnniorn hImo forbid the use of tin? j^alvnnic 
 current, on account of their poor vitality, and their liability 
 to break down and produiie systemic poisoning. 
 
 The cases reiK)rted, in which fibroid tumors art'^ said to 
 have disappeared, are rari^ <u)nsi(lerinf^ the number tn^ated. 
 In the lar^e majority tluTe is a p(^rceptible diminution in 
 size which persists for a longer or shorter period. For the 
 application of the j^alvanic current to uterine fibroids, the 
 large flat electrode is placed over the abdomen and the 
 intra-utc^rine pole to be used will (h^pend upon the results 
 desired. The i)ositive pole is to be used when it is desired 
 to affect the mucous membrane especially, and to arrest 
 hemorrhage; the negative for electrolytic treatment. For 
 the escharotic effect, thirty to fifty milliamperes during 
 ten minutes and repeated a few times, will usually be 
 sufficient. For electrolytic treatment the power is to be 
 gradually increased up to the extreme limit which the 
 patient will bear. Five to ten minutes will be sufficient, 
 and the time for the repetition will b(> determined by 
 observing the effect upon the tumor and upon the patient's 
 general condition. 
 
 Ectopic [fcsidtion. Both the Farad ic, and galvanic 
 currents have been recommended to destroy the lift^ of the 
 fcetus previous to the fourth month. With the iiresent 
 knowledge of the extreme dangers surrountling ectopic 
 gestation, increased often to their greatest intensity by 
 even the slightest maniiiulation, it can scarcely be con- 
 sidered safe to submit a patient to the manipulation 
 necessary for the application of either current. 
 
 Crtjliotomy is a much safer procedure, and consequently 
 the use of the electric current can only be consideretl 
 justifiable in localities far remote from skilled hands, or 
 where removal or delay means grave danger, or in cases 
 where ^he patient positively refuses to submit to ccDliotomy. 
 
PART TWO. 
 
 FUNCTIONAL DISEASES. 
 
 CHAPTER XII. 
 
 DISORDERS OF MENSTRUATION. 
 
 Abnormal changes in the menstrual flow are to be 
 rc^nrdt'd only ah symptomH whieli linvi^ thoir origin often 
 in opposite couditions and retpiire diHcrimination in 
 their treatment. Tlie menstrual tiow may be absent 
 (<n)i('H(>n'luv(() or scanty; it may be painful {(lijsnioi- 
 orrlnvd) ; or it may be profuse {)iK'ii()rrlHt<ji(i). When the 
 hemorrhage is profuse at other times than at the menstrual 
 period, it is termed mciron'luuiia. 
 
 AMEN()RRH(EA. 
 
 Amenorrhoea, or absence of the menstrual discharge, 
 is termed ])i'iniarij, when the patient has never men- 
 struated, and secondary, when menstruation has previously 
 occurred. 
 
 Primarij (imenorrha'a may be divided into {a) prim- 
 (irif pcrmdnciit amcnorrhivd, the most marked cases being 
 those in which the ovaries, or uterus, or both, continue in 
 a rudimentary condition, or are altogether absent, while 
 the external genitals are normally formed, {h) Primary 
 fcmporarij amcnorrJuva may be due to chlorosis occurring 
 in girls under the age of puberty. Menstruation occurs 
 later than normal, and, when it does set in, the flow is 
 scanty and of short duration, (c) Delayed lyuherfy. 
 Here the general and sexual development is complete, yet 
 the girl fails to menstruate. It is often caused by over- 
 work, combined with insuffirnent food, by change of 
 
1()8 MliDIC'AL AND SUIUIIC'AL OYNEfOLOOY. 
 
 {ilimiiti^ or luibitH ni about, the (<x[)'H't('(l [U'riod. or by too 
 long coiiliiKMiuMit (luring acliool lioura, combined witli an 
 ovor-taxt'd bra.'u. 
 
 Sccomldi'ff (imcnon'h<v(( may b»' di.. to rormtitutional 
 dcrangomiMits, as antomia, chloroHiH, diabi^toH, Hriglifn 
 (liHt'aso, malaria, cancorouH carlicxia, tubi^rcudosiH, or acuto 
 ilhu'HHCH. or i^ nuiy bo diu> to the intlucncc of tho norv.niH 
 HyntiMU. Huoh as Hovore mental Hhoek. alarm or Huddtui 
 fright, or by tho norvouH system generally being overtaxed. 
 Among other causes may be mentioned obt^sity, change of 
 climate, sea voyagi's, and sudden or prolongc^d exposure to 
 cold, particularly at the menstrual periovl; or it may bo 
 due to accjuired atrc^sia f)f the cervix, or of the vagina. 
 Kemoval of both ovaries does not always lead to complete 
 amenorrluua, some women (continuing to menstruate for 
 years after their removal. There are ditt't^rent explanations 
 given, among which may be mentioned, the existence of a 
 supplementary ovary, by a portion of the ovary being left 
 in tho pedicle, and by tho law of "persistence of habit." 
 
 Symptoms. Besides the absence of the periodic flow, 
 whi(ch is of course tho chief symptom, there are other 
 symptoms to be taken into consideration, and which are 
 for the most part tho.se of the primary disease causing it. 
 
 When a case of amonorrluBa presents itself, it should 
 detinitoly bo setthnl whether it is primary or secondary. 
 Primary amenorrhom, in which the menstrual flow has never 
 occurred, leads to questioning whether the uterus, tubes, 
 and ovaries be present in their entirety. If present, it 
 becomes necessary to ascertain whether atresia of the 
 cervical canal, vagina, or vulva exists. If tho prodromic 
 symptoms of a menstruation be absent, it points to con- 
 genital deficiencies, but if the prodromic symptoms have 
 been present, and repeated at lunar intervals, with no 
 menstrual flow, suspicion of atresia is excited. If the case 
 be one of secondary amenorrhoia, pregnancy and lactation 
 must bo excluded. When arising suddenly, as for 
 
DISOUDEUa OF MENSTRI^VTION. 
 
 im 
 
 iiistaiico, from taking cold, huoIi HymptomH nn fovor, rnther 
 Bovero ht>ft(Iu(On% paiiiH in tlu'^ back and pelviH and oxtiMul- 
 in^ down tiw thij^liH, with irritability of tin- bladdt^r nnd 
 bowels, ^oncrally appear. 
 
 Diagnosis. Tlio most important <u)ndition from which 
 it niuHt he (tan^fully dia^noHed is pn-^nancy, normal or 
 ectopic. Evt^ry Hij^n of pre^nanc^y, parti(udarly tht^ early 
 oncH, must be thought of and carefully brought to bear 
 ui)ou the caHt\ Upon tluB point the prat^titioner must 
 "Iwiys be on his guard. Designing women ofttMi consult 
 .. physician for anuMiorrhoMi, when they know tlu^y are 
 pregnant, hoping that something will be done to bring on 
 their courses and thus interrujjt gestation. 
 
 Treatment. Before any line of treatment can be satis- 
 factorily establisluHl, a correct estimate of the symptoms 
 must be madi^ and a conclusion arrived at, whether it is 
 physiological or pathological. If the former, no treatment 
 is needed; if the latter, the treatment will vary according 
 to the special cause and must aim at the correction of the 
 underlying morbid conditions. Hot hip and foot baths 
 are generally useless, unless the function is about to 
 appear. It is not uncommon for the menstrual function 
 to be delayed for one or more years, or to be irregular, or 
 8usi)ende(l, for the first few years after its commencement, 
 and hence no special remedy is needed, except attention 
 to hygiene, diet, dress, exercise, and baths. The uterus, 
 in such cases, being imperfectly developed, time must be 
 allowed for its normal growth. Acute suppression, such 
 as that arising from cold, is bost treated by rest in bed, a 
 hot sitz bath every six hcurs, with a warm water vaginal 
 douche at the same time, and by the administration of a 
 laxative. Hot water bags applied to the abdomen and 
 lumbar region, pediluvia with mustard and water assist 
 frequently in giving r(^lief. The use of the so-called 
 direct emraenagogues, as rue, savin, and cantharides, is 
 objectionable. The uteriiu^ function should never be forced 
 
110 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 when the geuornl system is struggling for existence; 
 besides very few remedies liave any direct stimulnting 
 effect on the lining membrane of the uterus. Amenorrhcoa 
 from malaria calls for the administration of qHiniiK' and 
 change of climate. Rheumatic amenorrluua sometimes 
 calls for the salicyldh')^. Ciniicifiu/d and (ina{(icu}ii are 
 excellent remedies for rheumatic amenorrluxja, but espe- 
 cially for delayed or painful menstruation. PnhatiUa 
 is indicated when the menses have been stopped by mental 
 shock or fright. Apiol is one of the most safe and 
 efficient emmenagogues, and may be given in capsides 
 containing five or six drops, three times a day, for a few 
 days preceding the expected tlow. 
 
 Aloes indirectly stimulates the internal genitalia, and 
 is one of the best adjuvants to other treatmejit when con- 
 stipation exists. Strijchnhic is a good muscle and nerve 
 tonic, and will assist the action of iron. Lron is the 
 hfBmatic tonic, and stands first. It has nn emmenagogue 
 action, increasing the blood supply of the pelvic organs, 
 and may be administered in any one of the recognized 
 forms, such as the dried sulphate, the carbonate, the 
 muriated tincture, either plain, or in the form of elixir or 
 glycerole. The citrates, tartrates, lactates, peptonates, or 
 other mild i)reparations are useful, but not so rapidly 
 efficient. The therapeutic effect of any of these can often 
 be improved by the combination of a small dose of liquor 
 potassre arsenicalis or liquor arscnuci hydrochlor. Bland's 
 pill, composed ci sulphate of iron and carbonate of potash, 
 or the modified pill which contains arsenious acid as well, 
 often gives excellent results. 
 
 Among the various combinations the following are 
 the most generally serviceable : 
 
 R. Aloui, grs. xii; 
 
 ]'il. Ferri Carb., drams isfir 
 
 Myrrh, dnim ss; M« 
 
 Ft. pil No. XL 
 
 Sig. — Take two pills, three times a day, after meals. 
 
DISORDERS OF MENSTRUATION. 
 
 Ill 
 
 R. Ferri Siili)lmt., Exsiccat., grs. xl; 
 Quiniii' Sulphat. , grs. xl; 
 Strychnia' Sulphat.,gr. i; 
 Ext. (ientian, q.s. M. 
 
 Ft. pil No. XL. 
 
 Sig. — Take one pill after tneala. 
 
 R. Ferri Sulphat., dram i ; 
 Pot<i8H. (!arb. , dram i; 
 Quiniii' Sill, 'iat., dram 88 ; 
 Ext. Nunc. Vom., grs. iv ; 
 Aloin, grq. iv. 
 
 Ft. pil No. XL. M. 
 
 Sig. — Take one to two after meals. 
 
 R. Tinct. Ferri Mur., drams v; 
 Liq. Arson. Mur., dram i ; 
 Acid Mur., C.P. dram i ; 
 Sj'rup Simplicis, ad., oz. viii. M. 
 
 Sig. — Dessertspoonful, in wine glass of water, after nteals. 
 
 Pofdssium pcrmaiu/aiKitc or blnovidc of mam/aiicse 
 sometimes verv efficnciou;?, when administered for a 
 few days precediiij? menstruation, but the former often has 
 a distressinjij eft'cot upon the stomach.. The k)cal usi^ of 
 electricity is the most reliabhi of all emmenagogues, being 
 the most direct \iterine stimulant we possess. It is well 
 adapted to stubborn, long continued cases, which have 
 resisted hygienic and medicinal treatment, more particu- 
 larly when the uterus has been found small and ill- 
 developed, or has been atrophied from superinvolution or 
 chronic metritis, or in cases in which the internal genitalia 
 have been found markedly dormant and atonic. 
 
 Vicarious menstruation is a condition closely allied 
 to amenorrluea. It means a condition of the female 
 system in which there is a regularly recurring discharge 
 of blood from other par' of the body besides the uterus. 
 The sanguineous flow may come from tlu^ nose, bron- 
 chial tubes, stomach, intestines, or rectum; generally it 
 comes from a mucous siirface, but it may take place from 
 the skin or at the site of a wound. The treatment 
 applicable is that adapted for ameuorrhoaa. 
 
112 MEDICAL AND SURGICAL GYNECOLOGY. 
 MENNORRHAGIA AND METRORRHAGIA. 
 
 The first of these two words is usod to oxpross nn 
 excessive menstruation ; the second, for n flow of blood not 
 only nt the menstrual time but between menstruntions. 
 Neither condition is a disease, but a symptom of some 
 well-defined pathological '■ ^udition. Women vary greatly 
 within the physiological limits in the amount, the dura- 
 tion, and the frequency of menstruation, and it is thus 
 difficult sometimes to say where normal menstruation 
 ceases and menorrhagia begins. Menorrhagia may occur 
 as an excessive flow of blood during the normal numbi^r 
 of days, or an ordinary flow extending over an excessive 
 number of days, 
 
 Causes. Hemorrhage associated with abortion, myo- 
 matous degeneration of the chorion, placenta previa, 
 retained membranes, and the like, are not to be considered 
 as having a place under this heading. Women of 
 hemorragic diathesis bleed more freely at the menstrual 
 epochs. Hremophilia, scrobutus, and purpura act in the 
 same way. Chlorosis, as a general thing, tends to 
 amenorrhcea, but in some cases it leads to menorrhagia 
 and metrorrhagia. Many other conditions dispose to it, 
 as long-continued mental depression and other nervous 
 disturbances, luxurious living and sedentary habits, resi- 
 dence in tropical climates, malaria, tubercle, the acute 
 exanthemata, lead and phosphorus poisoning, and 
 Brlght's disease. 
 
 It may be associated with disorders of the circulation, 
 such as mitral incompetence or stenosis; congestion, from 
 any cause, of the portal circulation; renal or splenic 
 disease; abdominal tumors, or even overloaded bowels. 
 The chief local pelvic causes are ovarian, uterine, and peri- 
 uterine congestions and inflammations; tubal inflammatory 
 diseases; the earlier stages of chronic metritis; subinvolu- 
 tion; chronic endometritis; cervical lacerations; diplace- 
 ments; uterine fibroids and polypi. 
 
DISORDERS OF MENSTRUATION. • 118 
 
 One of the most common onuses is the jirosence of 
 fungositios within the uterine oivity; and malignant 
 diseiises of the uterus is nhnost invariably followed by 
 menorrhagia and metrorrhagia. Many women firmly 
 believe that the menopause must be attended by an 
 excessive menstrual flow. Such is not the case; after thti 
 menopause has once been established, post-climateric 
 hemorrhages are almost invariably due to a local lesion, 
 such as senile catarrh, cancer, or the presence of mucous 
 or fibrous polypi. 
 
 Tr('((f)ii('nf. The treatment of menorrhagia resolves 
 itself into that aijpropriate for the attack, and that for the 
 menstrual interval. Rest in bed, in the recumbent position, 
 should be insisted on, light non-stimulating diet, the 
 — ictum unloaded and the bowels kept open. Chronic 
 jnstipation, particul- "ly when associated with congestion 
 of the portal circulation, is to be overcome by a pill of 
 podophyllin and nux vomica at night, followed, in the 
 morning, by a teaspoonful of some saline, such as effer- 
 vescing granular phosphate of soda, or a wineglassful of 
 Hunyadi Janos water. 
 
 The medicinal hemostatics to be used must d(>pend 
 ui)on the provoking cause. In moderate, persistent, erratic 
 hemorrhage, particularly where the fault lies in the heart's 
 action, or in a retarded venous circulation, (lij/itdli)^ is one 
 of the best remedies. It operates by increasing the arterial 
 tension and thus improves the atonic circulation. Enjot 
 is singularly well adapted to conditions of the uterus in 
 which there are well developed, but relaxed muscular 
 fibres, with dilated and engorged blood vi^ssi^ls. The more 
 soft, flabby, relaxed and engorged with blood the uterus is, 
 the more pronounced will be its effects, hence it is partic- 
 ularly indi(!ated in chronic hypenemia, active or passive; 
 in chroiiic metritis, in its first stage, and in subinvolution. 
 Hiimamclis, in the form of fluid extract, is a most usi^ful 
 remedy. For sudden outbursts and for active and profuse 
 
114 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 hemorrhage it is inferior to c^rgot, b\it for n slow long 
 continuous flux, or hemorrhngo pnssivo in chnracter, it is 
 the remedy j)a?' excellence. The fluid extract of ergot and 
 hamamelis make an efficacious combination. Hydrastis 
 Canndeiisis is a vaso-constrictor in congested states of 
 relaxed mucous membrane and for uterine hemorrhage, 
 due to endometritis, myomata, or incomplete involution, it 
 is very valuable. It also combines well with ergot. A 
 neat way of administering is in the form of hijdt'dstine, 
 given by the mouth or hypodermatically in a ten per cent, 
 solution. 
 
 The following combinations have been found very 
 serviceable : 
 
 R. (•allic acid, dram i; 
 
 Ergot, Fluid Extract, oz. ss; 
 Acid Sulph. Aromat, drams iiss; 
 Elixir Simplicip, ad., oz. viii. M. 
 
 Sig. — A table«{>oonful in some water every four hours. 
 
 R. Ergot, Fluid Extract, oz. ss; 
 
 Hamamelis, Fluid Extract, drams iii; 
 Tinct. Hyoscyam, drams iiss; 
 Elixir (Jentian Co., oz. i; 
 A(juas ad., oz. viii. M. 
 
 Sig. — A tablespoonful in some water three times a day after meals. 
 
 Thicfure I)i()if(dis, drams iiss, may be combined with 
 either of these, should the indications call for it. 
 
 The action of medicinal agents should be supplemented 
 in severe cases by local applications. Hot water may be 
 injected into the vagina, and when the patient has 
 become deeply aniemic from loss of blood, normal salt 
 solution may be injected into the rectum. The best non- 
 operative means is the vaginal tampon. The vagina and 
 cervix may be tamponed with absorbent cotton after the 
 hot water irrigation and allowed to remain there for 
 twenty-four hours. During the intervals, the judicious 
 and thorough use of the currette is one of the best means 
 of promptly and safely curing many of these cases. 
 
 Local galvanization of the uterus is a therapeutic 
 agent worthy of the highest consideration in uterine 
 
DISORDERS OF MENSTRUATION. 115 
 
 hemorrlingo (loppiidont upon uterine fibroids nnd chronic 
 nfpections of the endometrium. Faulty conditions of the 
 blood from niiiinnin, chlorosis, or defective hygiene, are to 
 receive special care. Iron, in the form of the nniridtrd 
 fiiicfurc, forms an excellent means for checking excessive 
 menstruation dependent upon marked annemia; however, 
 in most causes it is to be utilized only daring the mens- 
 trual interval. Arsenic is a most valuable hemostatic in 
 the menorrhagic conditions of young girls, as well as of 
 women nearing the menopause. At such times, if too 
 profiise, too frequent, or continues too long, it is best met 
 by administering threi^ to five drops of liquor potassse 
 arseuicalis three times a day. It seems to be indicated 
 when iron is contra-indicated, and may be given during 
 the time of the flow as well as during the interval. A 
 generally favorite prescription is known as the combination 
 of the sulphates. 
 
 R. Magnesia' Siilpli., dniins vi; 
 
 Qiiiniii' 8ulph., grs. xxv; , 
 
 Ferri Sulph. Exsiccat, grs. xl; 
 Acid Sulph. Aroinafc. , drams iis.s; 
 Acjua Mentha' Pip., ad., oz. viii. M. 
 Sig. — A tablespoonful in a wineghi.ssof water after meals. 
 
 R. Pulv. Ferri Redact., grs. xl; 
 Quiniie Sulph., grs. xl; 
 Acid Arseniosi, grs. i; 
 Extract (ientian., (js. M. 
 
 Ft. pil No. yh. 
 
 Sig. — One pill after each meal. 
 
 Precocious menstruation is a regular lunar flow of 
 blood from the genitals every four weeks, occurring in 
 children below the age of puberty. As a rule, both the 
 external and interal genitals and the breasts are abnor- 
 mally developed in such children, and sometimes they show 
 sexual appetite. Nothing can be done for them except to 
 keep up their strength, and such other treatment as will 
 make uj} for the loss of blood, until they have reached 
 the proper period. 
 
lift MEDICAL AND SURGICAL OYN.EC()L()GY. 
 
 DYSMENORRH(EA. 
 
 Dysmenorrhcea means difficult or obstructed men- 
 struation. It is one of the most common of the various 
 menstrual deranfj^ements, and manifests itself by pain, 
 which varies greatly as to frequency, duration, time aud 
 severity. It may properly be divided into the following 
 varieties: — The ncuvdlf/ic, the rofUfCfit ire or injUimmaiovji, 
 the ohstnictivc, and the mcmhrcmous. To this classifica- 
 tion the ovdvlan has been added by some authorities. It 
 differs from the others more in location than in kind, and 
 it can scarcely be said to deserve recognition st^parate 
 from the inflammatory. 
 
 Spasmodic dysmenorrhcea is a term applied to the 
 neuralgic form, in which there is spasm of the circular 
 fibres about the os internum. 
 
 Neuralgic dysmenorrhcea. This variety does not 
 depend upon any appreciable organic disorder of the 
 uterus or of its appendages. Ordinarily, on the most 
 careful physical exploration, no alteration in size, shape, 
 position, consistency, or vascularity of the pelvic organs 
 or structures will be noticed. The sentient nerves of the 
 endometrium appear to be in a state of hyi^eraisthesia — a 
 neuralgia in the ordinary sense of the term. 
 
 Cduscs. There are many agencies which, at times, so 
 alter the healthy state of the nerves as at one time will 
 produce a gastralgia, at another an occipital or facial 
 neuralgia, and similarly in neuralgic dysmenorrhooa there 
 is present a local neurotic state, provoked to the excita- 
 tion of pain by the stimulus of the physiological congestion 
 incident to the oncoming menstruation. The causes which 
 generally induce it are: The neuralgic diathesis, hysteria, 
 chlorosis or plethora, malaria, gout, rheumatism, luxurious 
 and enervating habits, and habits deteriorating the ner- 
 vous system. 
 
 Symptoms. It is by far the most frequent variety, and 
 is found oftenest in those who are subject to the various 
 
DISORDERS OF MENSTRUATION. 117 
 
 neurotic discnses. The pain mny show itself before the 
 flow hns been established and disappi^ar as soon as it 
 comes on, or may continue with varying intensity throuj^li- 
 out the duration of the menstrual discharge. The pain is 
 located in the uterine or ovarian regions and radiates 
 towards the iliac, abdominal, lumbar, or sacral region, or 
 down the thighs. The discharge may be scanty or profuse, 
 and the severity of the pain seems to bo in inverse propor- 
 tion to the quantity of the flow. The diagnosis is made 
 by the exclusion of the other varieties. The pain felt in 
 the uterus has nothing expulsive in its character, the flow 
 is steady and not interrupted, no clots are discharged by 
 spasmodic efforts, and physical examination discovers no 
 obstruction. These facts will distinguish it from obstruc- 
 tive dysmenorrhoea. It is differentiated from the conges- 
 tive form by the absence of constitutional disturbance and 
 by its being habitual and not exceptional, by the absence 
 of the ordinary signs of endometritis and of ovarian and 
 pori-uterine inflammations. 
 
 The trcdtmcnt resolves itself into that which is appro- 
 priate for the time of the flow, to relieve pain, and that for 
 the interval, to remove the cause and prevent its repetition. 
 If the rheumatic or . gouty diathesis *>xists, it may be 
 combated by administering half dram doses of the 
 ammoniated tincture of guaiacum. by twenty drop doses 
 of the wine of colchicum, or by Ave t'^ ten grains of soda 
 salicylate, three times a day. In amemic and neurasthenic 
 cases ferriagineous and nerve tonics such as iron, nux 
 vomica, phosphorus, quinine, cod liver oil, malt extracts, 
 and the hypophosphites should be given, and the strictes*^ 
 attention to general hygiene observed. If plethoric, a 
 strict plain dietary should be demanded, and administra- 
 tion of such purgatives and saline medicines as will favor 
 the portal circulation and deplete the system generally. 
 
 Malarial toxeemia should be treated by quinine and 
 change of residence. A sea voyage will often accomplish 
 
118 MEDICAL AND SURGICAL GYN.ECOLOdY. 
 
 excellent rosults. Local fnrmliziition with the secondary 
 current in UHefu!, but often the bcBt rcHults are to be 
 obtaintul from the galvanic, with the positive i)ole intra- 
 utiirine. For relief at the menstrual pt^riod tlu^ use of 
 opium and cldoral should be forbidden, except under 
 extreme necessity. Phenacetint> in five to ten grain doses 
 often gives almost immediate relief. Tincture of cannabis 
 indica, in doses of ten to fifteen drops every four liours 
 while the pain is severe, is also beneficial, and should be 
 tried before resorting to opium or chloral. Apiol. in 
 five drop capsules, given three tinu^s a day for a f(^w days 
 before the flow is expi'cted and continued mon^ often 
 during the fiow, has done excellent service, especially in 
 the amenorrluvic forms of dysmenorriuua. Tincture of 
 Pulsatilla, given three times a day for at least three days 
 preceding the painful period, is indicated in the neurotic 
 types of the disease, especially in young women. Tincture 
 of cimicifuga. given three times a day during the whole 
 interval and more fre([U(uitly at the menstrual period, is 
 useful in the neuralgic and rheumatic forms. Viburnum 
 prunifolium, in the form of fluid extract, often gives good 
 results when administered in half dram doses for a few 
 (lays before the exijected period and continued during it. 
 This treatment may be supplemented by hot vaginal 
 douches and the introduction of one-fourth grain sup- 
 positories of extract of b(>lladonna. 
 
 Congestive or inflammatory dysmenorrhi^a. At 
 each menstrual period an active congestion occurs in the 
 mucous membrane of the Fallopian tubes and uterus, as 
 well as in the ovaries, and probably to a less degree in the 
 pelvic tissues. When any abnormal influence renders 
 this excessive, it naturally produces pain in the nerves 
 lying between the distended vessels. This excessive 
 hypericmia, which may result from a mechanical cause, as 
 a displacement of the uterus, or from a vital cause, as the 
 peculiar condition which we know as inflammation, gives 
 
DISORDERS OF MENSTRUATION. 
 
 U\) 
 
 rise to n vnrioty of painful inouHtruaticu which has boeu 
 styled congostivo or inHammatory. 
 
 Causes. In a groat many cases inHanimation of the 
 uterine mueou.^ membrane is the cause of this form of 
 (lysmenorrluDa. The existence of disease in this part 
 causes perhaps little pain until aroused by menstruation. 
 It may result, however, from almost any i)elvic inflamma- 
 tion which alters the condition of the m^rves immedialely 
 affected by ovulation or menstruation, or from any c luse 
 which exaggerat(>s and prolongs the congestion excited by 
 ovulation. Chief among these may be mentioned general 
 pk>thora, exposure to cold and moisture, sudden mental 
 disturbance, disturbed portal circulation, displacements of 
 the uterus, fibroids of the uterus, areolar hyperplasia, 
 endometritis, pelvic cellulitis, and peritonitis. 
 
 Si/mplonis. The patient, who has previously men- 
 struated painlessly, is seized during a period with severe 
 pelvic pain, accompanied by di munition or cessation of 
 the discharge and considerable constitutional disturbance. 
 The pulse becomes full and rapid, the skin hot and dry, and 
 with these there is headache, nervousness and restlessness, 
 and occasionally rectal and vesical tenesmus. In cases in 
 which a local inflammation exists, when the flow begins 
 or before that time, the patient suffers from dull, heavy, 
 fixed pelvic pain, which lasts until the process is ended, 
 and even afterwards. If it be due to hypenemia, the 
 suddenness and constitutional disturbancew will mark its 
 difference from the neuralgic and obstructive form, and if 
 it be due to the influence of existing pelvic inflammation, it 
 will usiially be marked by jjain during the inter-menstrual 
 periods, by difficult locomotion, fatigue after exertion, 
 leucorrhoea, and such like. 
 
 Treatment. As in the neuralgic form, the source of 
 the trouble must be sought for and combated along the 
 lines laid down for the treatment of that particular form 
 of disease. General or local plethora must be relieved, 
 
120 MEDICAL AND SURCUCAL (iYN/Ct'OLOGY. 
 
 (liHplntHMnoiitH and versions ovorcom(% and if niiy lociil 
 iiiHamination bo diHooveriMl, it should hv tlio subjoct of 
 trontmcnt. Should the fittnc-k bo nccidoutal nud duo to 
 hypi^raMnin moroly, as from oxi)OHuro to cold and nioisturo, 
 the patient had better be put to bed, hot applications 
 applied over the hypogastric and lumbar rofjfioiiK, and a 
 hot vaginal douche administorod every four hours. A 
 saline pur^e is to be ^iven, and a febrifuge mixture com- 
 posed of the following administered: 
 
 R. Tinct. Aconit., dram 88; 
 
 Liciuor Ammonia! Acefcatin, o/.. 188; 
 Spirit .'Ether, Nit., drums v; 
 Atjuii', ad., oz. iv. M. 
 
 Sig. — Uessertsjwonful in Home water every two liourw. 
 The pain may be relieved by phonacetino or by small 
 repeated doses of Dover's powder. 
 
 Should local inflammatory conditions be discovered to 
 bo the cause of the dysmenorrhfea, a small cotton tampon, 
 impregnated with boro-glycorido, with or without the 
 addition of a few drops of fluid extract of belladonna, and 
 inserted behind the uterus, will often give marked relief. 
 A five per cent, solution of ichthyol in glycerine applied 
 in the same way will act in a similar manner. 
 
 Local applications of heat and vaginal douches will 
 
 also act as valuable adjuvants. The internal administration 
 
 of bromide of ammonia, or of tincture of cannabis indica, 
 
 combined with liipior ammonia acotatis, spirits of ammonia 
 
 aromat and peppermint water, will have a decided soilntivo 
 
 effect, and tend to relieve the congested state. 
 
 R. Ammonia' Bromid., oz. ss; 
 
 S[)t8. Ammoniiv Aromat, oz. i ; 
 Li(|. Ammoniiu Acet !. i ; 
 
 Aqua> Menth. Pip., oz. viii. M. • 
 
 Sig. — Table.spoonful in some water every four hours. 
 
 Obstructive dysmenorrhoea. If after the blood has 
 
 collected in the uterine cavity any obstruction exists to 
 
 prevent its escape into and through the vagina, sijasmodic 
 
 pains are excited which often amount to uterine tenesmus, 
 
DlSOUbEUS OF MENbTUUATiON. 121 
 
 and (irc^ very Himilar to the (WpulHivi^ paiiiH xHuirrinjjf 
 (luring iioriiml labor. To tliiH form of painful uumi- 
 struatiou tin* name obHtriuitivi^ (lyHnuMiorrluua \uxh boon 
 applied. The obHtruction may exist in tho corvix or os, in 
 the vagina, or at the vulva. 
 
 The special raiiscs of obstructive dysmenorrhcua aro 
 con^^enital or acciuin^d contraction of the cervical canal, 
 such as is found in the elongated and (lonoid infra-vaginnl 
 cervix, with pin-holo os, or that form arising from chronic 
 intlammation, especially inrtammation resulting from the 
 vicious use of strong caustics. Flexions of the uterus, 
 especially wlien the angle formed is sharp, will produce it, 
 more particularly when associated with version. Vaginal 
 stricture, either congenital or acquired, will prevent the 
 free escape of blood and produ<!e uterine tenesmus, and 
 in like manner the hymen may produce the same effect. 
 Sometimes a small polypus comes down to the os internum 
 and resting upon it, acts upon the principle of the ball 
 valve, and by so doing produces the worst features of 
 obstructive dysnienorrluua. A fibroid in the parenchyma 
 of the cervix, by producing tortuosity of its canal, will 
 cause a similar effect. 
 
 The s///«7>/o;».s are characteristic. After menstruation 
 has continued for some hours, and sufficient blood has 
 collected in the uterus to distend it, a spasmodic pain 
 occurs in the jK^lvis, increasing into a more or less violent 
 expulsive eft'ort, like the contractions attending a mis- 
 carriage. This, in time, causes the passage of a certain 
 amount of blood, the pain then ceases and the patient is 
 relieved, until further distension and obstruction occurs, 
 when the process by which the uterus empties itsel'; is 
 repeated. These symptoms are so marked and decided 
 that little difficulty will be experienced in a diagnosis, but 
 before a decision is arrived at, a careful physical iwamin- 
 ation should be made, to discover the cause and thus place 
 the matter beyond doubt. 
 
122 MEDICAL AND Sl'lU;iCAL UYN-ECOLOOY. 
 
 Trcdttiiciit. Till' ln>Ht rccoj^iii/t'd trcatmciitof onlinary 
 cftH(^H of iu'rvi(Mil o()iiKtri(^ti()n, wlu'thcr u('([uirc(l or con- 
 j^i'iiital, is (lilutHtloii by incanH of j^radiiatcd dilators, or 
 more fonribly by iiu^aiiH of (loodi'lTH or some otluT nivrl 
 dilator. Wlu'ii the conHtrictioii docK not cxiKt within tlio 
 ciTvicMd (^anal. it in usually tlio rcKult of Homo Ht'vrro 
 intiammation following; tlu^ uh(^ of caustics, or of a (u»rvical 
 laceration, and in such (^ascs it may be found ninu'ssary to 
 lay opiMi the oh by cutting with a knife or wussors. Tn 
 order to keep the cervix or os patulous, the dilators may be 
 introdu<^ed from time to tinu\ but the method is painful 
 and often unsatisfactory. The difficulty may be overcome 
 by at onci> inserting a glass or aluminum intra-uteriiui 
 stem pessary and rt^taining it in place by means of 
 tampons friupiently changed, or better, by a Thomas' cup 
 pessary, allowing the pessary to be worn for two or three 
 months. The intra-uterine stem pessary is the best 
 method of treatment, after the canal has been straightt^ned, 
 for constriction arising from flexion. Obstruction, arising 
 from vagitml stricture or obturator hymen, may be ov(^r- 
 come by dilatation or incision. Polypi and submucous 
 fibroids in the cervix are to be at once removed. 
 
 Membranous dysmenorrhcea. This variety consists 
 in the exinilsion from the uterine cavity at menstrual 
 periods, of organized material, which is found to consist of 
 structures resembling the lining membrane of the uterus. 
 It may consist of a sac representing the triangular cavity 
 of the body of the uterus, with its three openings, or it 
 may come away piecemeal, in shreds, or as strips of 
 mucous membrane. When more or less complete it is 
 soft, comparatively tliK-k, and with many perforations, the 
 sites of the utricular follicles. Under the microscope the 
 cast is found to consist of the lining membrane of the 
 uterus hypertrophied in all its elements, almost exactly as 
 in pregnancy, lieMice it has been termed " menstrual 
 decidua." There are many views held as to its etiology, 
 
DIS'.UUEUS OF MENSTRUATION. 
 
 123 
 
 l)ut the two nmin oiu>h nrc, first, tliat it \h an exfoliation of 
 the entire nuK^ouH membrane of the uterine body (hi(> to 
 irritation transniitted to it, the rt'Hult of some ovarian 
 (list'ase. This view is tho one most fre([ia ntly accepted. 
 Second, that it is an exudation, thrown out ovi^r tiio 
 ut(>rini^ wall, the result of endometritis, and tH)nstitutinj^ 
 a caste of the uterine cavity. 
 
 Membranous dysmenorrho^a may be confoundi'd with 
 early abortion, blood casts or fibrinous moulds of the 
 
 Fn;. 3g. — A Dysmenorrhtual Membrane laid open. ■ 
 
 uterus, or with exfoliation of the vaginal mucous membrane. 
 From the first of these, the differentiation may be accom- 
 plished by the progress of the case, the repetition of tho 
 pr- ^ess, and the caitire absence of the symptoms of 
 l^regnancy, wliile tiie microscope will show the absence of 
 villi of the chorion and of tho large irregular decidua 
 cells. Blood clots and vaginnl exfoliations will also be 
 readily recognised by the microscope. 
 
 Sij)iij>t(niiii. With the commencement of the menstrual 
 flow there are steady pains which iucrense as it progresses 
 
 I 
 
124 MEDICAL AND SURGICAL aYN//COLt)GY. 
 
 until tlioy become violent nnd expulsive, like those of 
 abortion. Under these the os gradually dilates and the 
 membrane is forced out into the vagina. Tlu^re is 
 commonly a tendency to menorrhagia, which however, 
 soon disappears, but for some tim(^ after it has passed off 
 there are symptoms of endometritis and purulent and 
 sanguineo-purulent discharges. 
 
 Trcafnioit. The uncertainty of the i)athology of this 
 disorder has led to a great variety of treatment. For the 
 pain which attends the attack, a hypodermatic of morphia 
 may have to be administered, and occasionally the pain is 
 so severe as to demand the administration of a little 
 chloroform or sulphuric ether, particularly when morphia 
 is not well tolei-ated. Hot applications and vaginal 
 douches, so useful in all forms of dysmenorrluua, are also 
 ai)plicable here. If uterine or ovarian disease be detected, 
 it should bo treated in accordance with general rules. 
 The largest number of cases successfully treati'd has 
 followed repeated dilatation and curetting cf the uterus, 
 in conjunction with applications of chloride of zinc or 
 carbolic acid, and packing with iodoform gauze. This 
 line of treatment may alternate with galvanization, ten to 
 twenty milliami)en^s, the negative pole intra-uterine. All 
 varieties of constitutional treatment have been tried and 
 abandoned. 
 
 Ovarian Dysmenorrhcea. In a number of cases, by 
 no means small, no disordered condition of the nervous 
 system will be found to account for habitual dysmen- 
 orrlnua, and exploration of the pelvis will fail to discover 
 uterine or peri-uterine disorders. By a careful bimanual 
 examination in such cases, a globular slightly compressed 
 mass, abo\it the size of a walnut or small egg, will often 
 be found in Douglas' cul-de-sac, or or one or both sides of 
 the uterus, low down and in close proximity to it. These 
 are the ovaries, enlarged, tender, prolapsed, and revealing 
 a condition known as chronic ovaritis. The pain in this 
 
DISORDERS OF MENSTRUATION. 
 
 125 
 
 form of dysmenorrlujoa precedes the flow by several days 
 and diminishes as it is established. It is of a dull 
 character, extends over the nates, down the thighs, and is 
 particularly liable to be accompanied by nervous mani- 
 festations and depression of spirits. The breasts often 
 sympathize, becoming painful to the touch. It must not 
 however be supposed that in all cases of enlarged, tender, 
 or prolapsed ovaries, ovarian dysmenorrhoea will be found, 
 nor in every case of ovarian dysmenorrhoea that the 
 ovaries will be found in tliis condition. 
 
 Tlie trcdtnirnf of this class of cases is perhaps the 
 least satisfactory of all classes of dysmenorrhcea. In a 
 young girl, in whom ovarian disorder has advanced only 
 to congestion, recovery may rapidly take place, but in a 
 woman further advanced hi life, and in whom chronic 
 enlargement of the ovaries has occurred, associated with 
 tenderness and prolapse, the prospects for cure are slight. 
 Sterility in tliese cases is the rule. It is just in .such 
 conditions that bad habits are to be contracted by the use 
 of alcohol, morphia, cldoral, or chloroform, and their 
 administration should be avoided as much as possible. 
 Hot applications, warm sitz baths, and warm soothing 
 vaginal injections should be employed. Internally there 
 is no remedy so efficacious as the bromides — tiai grains of 
 bromide of ammonia or soda every four hours, commenced 
 a few days before tlie fion' and co^itinued until its close. 
 For the immediate relief of pain, phenacetine, exalgine, 
 cannabis indica, or monobromate of camplior may be 
 employed. Locally, in addition to the hot applications 
 and douches, a boro-glyceride tampon, impregnated with a 
 few drops of fluid extract of belladonna and inser<^'^d behind 
 the uterus, soothes and relieves the local irritation and 
 congestion. When unmistakeable evidences of organic 
 ovarian disease exist, the operation for the removal of one 
 or both ovaries is advised as the only means of giving 
 relief. 
 
126 MEDICAL AND SURGICAL GYNiECOLOGl. 
 
 In treating the subject of dysmenorrhoea, all the 
 Vftrioties generally indicated by autlioriti(^s have been 
 included, because, by the adoption of this method, a more 
 thorough investigation of the subject is secured, and a 
 recollecticn of them at the bedside will often aid in the 
 classification and treatment. It must not, however, be 
 supposed that every case of dysmenorrhoea will be sub- 
 jected to strict limitations, on the contrary, many, if not 
 most cases, give evidence of one or more disturbing 
 elements. As for instance, a retroversion occurring in a 
 weak' nervous woman with impoverished blood might 
 cause a dysmenorrhoea, due in part to mechanical obstruc- 
 tion, in part to neuralgia, in part to congestion, and, 
 perhaps to some extent, to a secondary endometritis. In 
 view of this fact, it is well to have in memory somt^ general 
 plan of treatment which may be resorted to in cases not 
 readily susceptible of classification. Hot wet or dry 
 applications to the abdomen and lumbar region, hot 
 vaginal douches, and rectal enemata have a place in the 
 treatment of every form. Medicated vaginal tampons and 
 suppositories aid in allaying congestion, in soothing the 
 pain, and in supporting the uterus and adnexa, and may 
 safely be used in almost every case. The administration 
 of a saline jjurgative will empty the bowels and relieve 
 portal or pelvic congestion; and for the relief of pain and 
 as a sedative to the nervous system, a judicious selection 
 from the drugs already referred to will oftcMi accomplish 
 much of the desired effect. 
 
STERILITY. 127 
 
 CHAPTER XIII. 
 
 STERILITY, NYMPHOMANIA, VAGINISMUS, 
 LEUCORRH(EA. 
 
 Sterility is nnothor functioiml disorder of the uterus, 
 and implies an inability for impregnation during normal 
 reproductive life. It is sometimes coiKjcnitdl, the result 
 of faulty development. It is said to be cicquircd when it 
 arises from disease after an uncertain period of fertility. 
 A marriage may be unfruitful from causes pertaining to 
 the male or to the female. More women than men are 
 sterile, in the proportion of six to one. Impregnation 
 becomes impossible from absence or a very incomplete 
 development of the vagina; from atresia of the vagina, 
 or from an imperforate hymen. Sterility may occur from 
 a condition of the vulvar orifice, called vagiiusmus, in 
 which all attempts at coition cause extreme suffering 
 (dyspareunia), the sphincter vagiiiie and muscles of the 
 pelvic floor being, at the same time, thrown into a spas- 
 modic state. It may arise from inability of the semen to 
 enter the uterine cavity owing to atresia or stenosis of the 
 OS, or to flexions, displacements, or tumors of the uterus. 
 The vitality of the sperm may be destroyed by excessive 
 acidity of the vaginal mucous. There may be incapacity 
 for proper ovulation, which includes any condition of the 
 ovary which impairs the ovule, such as chronic ovaritis 
 and cystic degeneration; from impt^rfect development of 
 the ovule, the result of debilitating diseases as amemia, 
 scrofula, tuberculosis or syphilis. Gonorrhoea, it matters 
 not how contracted, is a very common cause. Sterility 
 may be owing to organic changes in the Fallopian tubes, 
 which prevents the safe passage of the ovum through 
 them; to pelvic peritonitis, which prevents an instinc- 
 tive application of the fimbrire to the ovaries; to inability, 
 after fecundation, to continue gestation; or, finally, to 
 want of physical adaptation of the parties, " sexual incom- 
 
128 MEDICAL AND SUROICAL GYNAECOLOGY. 
 
 patability." Mnrried life may bo sterile for years, yet 
 when either party obtains a new companion fertility may 
 follow. 
 
 Treatment. While judicious treatment occasionally 
 gives favorable results, it often terminates in disappoi it- 
 ment. Success in the managt^ment of sterility depends 
 largely upon a correct diagnosis, and the special I'atment 
 of all varieties consists in the riunoval of the cause, if 
 practicable. In all cases of long-continued sterility, after 
 having thoroughly examined the female without finding 
 a satisfactory cause, investigation should commence with 
 the male. If the uterus is absent or small, less than an 
 inch or an inch an a half in length, all efforts to ensures 
 fertility would seem hopeless. An ill developed uterus 
 may be stimulated to growth if the patient is young and 
 healthy. Excessive acidity of the vagina may be overcome 
 by the use of alkaline waters internally, and by v .ginal 
 injections of weak solutions of carbonate of potash prior 
 to coitus. 
 
 Nymphomania. When the sexual feeling in the 
 female is excessive or perverted it is called nymphomania. 
 There is a mental perversion, attended by an uncon- 
 trollable sexual passion, which, in its most severe form, is 
 often associated with or dc^pendcnt upon certain varieties 
 of insanity with or without gross brain disease. Although 
 observed in children and octogiuiarians, it occurs most 
 frequently at the beginning and at the end of men- 
 strual life. There is the greatest perversion of the sexual 
 act, gratification being sought not oidy in masturbation, 
 but also with others of the same sex. In many instances 
 the disorder is a reflex manifestation arising from irrita- 
 tion of the genital organs, or from certain diseases of the 
 uterus and appendages. The exciting causes may have 
 their origin in the intestines, especially in the rectum, 
 such as by the presence of worms or hemorrhoids. Inflam- 
 mation of the vulva, vagina, urethra, bladder, or the 
 
NYMPHOMANIA, VAGINISMUS, LEUCORRHCEA. 129 
 
 irritntiou of diabctio urine may give rise to it. Nymplio- 
 maiiin inny also result from freciueut masturbation as well 
 as cause it. 
 
 Treatment. The best results are obtained by moral 
 suasion. Occupation of the mind and free physical 
 exercise in the open air, early rising, cold bathing, 
 regularity of the bowels, a plain non-stimulating diet, and 
 the internal administration of the bromides, are the best 
 remedies. When local disease is suspected, it is to be 
 sought for and treated. Clitoridectomy and oorphorectomy 
 have been tried and have failed to effect a cure, and such 
 operations are indicated only when incurable disease of 
 the external genitals or ovaries respectively perpetuate 
 the condition. 
 
 Vaginismus. Vaginismus consists of hyperajsthesia 
 of the vulvo-vaginal orifice and neighboring parts, accom- 
 ])anied by abnormal and painful contraction of the 
 muscles of the pelvic floor. It is not a disease in itself, 
 but a symptom of various morbid conditions of the vulva, 
 vagina and the surrounding parts, among which may be 
 mentioned urethral caruncle, erosion, inflammations or 
 fissures of the vulva or hymen, rectal fissures, cervical 
 lacerations, and uterine and ovarian displacements. 
 
 Tri'dtumit. The cause of the local irritation is to be 
 removed and the general health improved. Gradual 
 dilataticni may be practised by introducing a series of 
 dilators, a larger dilator being used and allowed to remain 
 for a longer period each succeeding day. Forcible 
 dilatation, under an ana^stlietic, may be practised, after 
 which a good sized glass or hard rubber dilator is to be 
 inserted and allowed to remain for several hours. 
 
 LEUC()RUH(EA. 
 
 By the term leucorrhoea is meant a " white flow," but, 
 in the ordinary acceptation, it is used to designate any 
 discharge, other than blood, coming from the genitals, 
 
130 MEDICAL AND SURGICAL GYN/ECOLOGY. 
 
 although nt times the leucorrlioeal discharge may have a 
 sanious admixture. In its normal condition tlu^ genital 
 tract is just moist enough to be soft and well lubricated. 
 For a day or two after menstruation many women have a 
 slight increase of moisture, but any decided increase, 
 whether mucous, senms, or purulent, is abnormal and 
 constitutes in itself, if not a disease, a symptom of one, 
 and one often of much importance. The discharge may 
 come from the vulva, the vagina, the cervix, or the interior 
 of the uterus. It may be colorless, white, yellow, green, 
 red, or brown. It may be nearly as thin as water, or more 
 or less thick, like cream or soft cheese. Leucorrhoea may 
 be idioixithic or stjniptotiiafic. It is called idiopathic 
 when it is not traceable to any definite disease, or patho- 
 logical condition, or to any permanent structural anatomi- 
 cal lesion. It is found often in young and anaemic girls, 
 in those of sedentary habits, or in those whose employ- 
 ment compels them to remain standing upon their feet 
 for hours. It may be induced by anything that weaktnis 
 the constitution, such as protracted lactation, bodily or 
 mental fatigue, emotions, especially of a depressing kind, 
 and is often found in persons predispt)sed to uulmonary 
 phthisis. Like other catarrhal affections, it nay be due 
 to exposure, or to residence in a damp climate; or it may be 
 induced by local irritation, such as masturbation or 
 frequent coition; or it may appear in consequence of 
 amenorrhoea or scanty menstruation. 
 
 Si/iiipfoiiis. Apart from the discharge, which, as a 
 general thing, is of a whitish color as it appears at the 
 vulva, there are often other leading symptoms. The 
 patient is often auipmic, has a pale, worn, tired, or pinched 
 look, and a feeling of general weakness. The appetite is 
 poor and the digestion impaired, giving rise to flatulence 
 and gastralgia or enteralgia; constipation and an irritable 
 bladder are frequently present. Backache is a character- 
 istic symptom. The patient complains of a dull heavy 
 
LEUCORUHCEA. 131 
 
 pnin over the sacrnl region, or at the tip of tlie ooccyx, 
 whioli may be continuous or may be brought about by 
 long standing or other fatigue. 
 
 Trcdtment. From the symptoms described it will be 
 readily seen that general and local treatmiuit must go 
 hand in hand. The more the condition depends on 
 constitutional causes, the more general must be the treat- 
 ment. Strict attention must be paid to general hj'^giene. 
 Plain substantial food that the stomacii can readily digest 
 must be taken, and the bowels kept open by some mild 
 aperient, such as a pill of aloin, strychnine and belladonna. 
 Tonics, particularly the ferrugineous and ni^rve tonics, 
 are here indicated, and an emulsion of cod liver oil is 
 often well borne, helping to liuild up the system. Such 
 inti^rnal remedi(^s as hydrastis and cimicifuga seem to 
 have the special virtue of checking leuchorrluua. Warm 
 hip or tepid general baths are to be recommended, and 
 night and morning a vaginal douche of hot water, followed 
 immediat(^ly by a warm astringent solution, may be used. 
 In many cases treatment carried out on these lines will 
 suffice to effect a cure, and is especially to be tried in 
 intact girls, before resorting to or suggesting a physical 
 examination. 
 
 Symptomatic leucorrhoea. Leucorrhom is a symptom 
 of numerous local diseases of the genitals, suc^h as vulvitis, 
 vaginitis, specific or otherwise; endometritis; metritis; 
 subinvolution ; erosion of the os ; lacerated cervix ; polypi ; 
 fibroids, or carcinoma. When even a mild leucorrlntial 
 discharge has resisted treatment for a considerable length 
 of time, or in cases in which the amount of discharge, 
 or its color or consistency, points to the ijresence of a local 
 disease, no time should be lost in making an examination, 
 and in treating the cause according to the pathological 
 conditions found to be the chief factors in the production 
 of the loucorrhcoa. 
 
PART THREE. 
 DISEASES OF SPECIAL REGIONS. 
 
 CHAPTER XIV. 
 
 DISEASES OF THE VULVA. 
 
 Malformations. 1. Absence of the vulva. By nu 
 arrest of developmont in tho first mouth of foitnl life, the 
 external genitals and nnus may be absent, the skin covering 
 the region uninterruptedly. If the nnus is formed life 
 may be continued without the external genitals, the urine 
 being evacuated through the navel. 
 
 2. Hi)i)(Hi})(t(li((S. In consequence of insufficient clos- 
 ure in the median line, the lower wall of the urethra may 
 be split more or less deeply. If the defect extends very 
 deeply so as to divide the different sphincters of the 
 urethra the patient cannot retain the urine. 
 
 3. Episjxidids is characterized by a lack of union of 
 the upper wall of the urethra. It is generally combined 
 with a similar defect in the anterior wall of the bladder 
 (extroversion). Epispadias, like hypospadias, has been 
 cured by plastic operation, such as stitching together 
 flaps derived from the mucous membrane of the vestibule, 
 or by uniting two lateral denuded surfaces in front of the 
 open urethra. 
 
 4. The clitoris is sometimes split in two lateral halves, 
 with or without cleavage of the urethra. It may be 
 absent, or very small, or, on the other hand, as large as a 
 medium sized ixniis. 
 
 5. The prepuce is frequently adherent to the glans, 
 and in many cases this condition gives rise to reflex 
 neuroses and even epilepsy and nymphomania. 
 
DISEASES OF THE VTLVA. I'iili 
 
 (). The l<tl>i<i miiioni may b(^ ahsoif, or it may bo 
 mnUi'itIc, each being Hplit lengthwise in two or three 
 flaps. 
 
 7. The hihid, nuijovd may likewise be split by longi- 
 tudinal ch^fts, or may extend so far back ns to reach 
 behind tiie anus so that there is no apparent perineum. 
 
 8. Hcmdphnxlisni. By this term is meant a congenital 
 malformation of the sexual organs, in which the germinal 
 gland of each sex (testicle in the male and ovary in the 
 female) is found in one and the same individual, together 
 with mori^ or less perfect organs belonging to both sexes. 
 Anatomically and clinically it may be divided into two 
 chief varieties, the true and the .'^/>?^•/o/^s•. or pHciulo- 
 hcnuiplirodinm. True hemaphrodisni may be divided into 
 three forms: bilaieml, in which an ovary and a testicle 
 are found on each side; unihiteraJ, in which an ovary or a 
 testicle is found on one side, and on the other both an 
 ovary and a testicle; and hiferal, in which an ovary is 
 found on one side and a testicle on the other. Fseudo- 
 henidphrodism is that condition in which the sc^xual 
 glands belong to one sex, either masculine or feminine, 
 while the passages leading from them, as well ns the 
 external parts, approach more or less the other. There 
 are two great varieties of this malformation, Andnuftpie, 
 in which a man simulates a woman both in the general 
 conformation and local appearance of his sexual organs; 
 and (jt/aitdrid, the far less frequent condition, in which a 
 woman simulates a man, the resemblance being confined 
 almost entirely to the external sexual organs. The clitoris 
 is elongated two or three inches and possessed of more or 
 less erectility, and perhaps the labia partially united so 
 as to have the appearance of a scrotum. 
 
 Tiie diagnosis of the sex is often difficult. A periodical 
 bloody discharge has even been observed to take place 
 from apparently normal male genitals, especially from 
 males suffering from hypospadias. 
 
IJU MEDK^AL AND SUR(JICAL OYN/ECOLOOY. 
 
 Tlu* fi'caliiiciif in pnuiticnlly nil. A liyiJOHjHidino 
 un>tlini may bo ri>Htoro(l, n blind vaj^iiml poiu^li (doHod, but 
 usually nothing can ho dono to restoro the partH to tluur 
 normal Htato. A liyp('rtroi)Iii('d (ditoris Kliould, of courH«.% 
 bo romovcd. 
 
 Hernia. Two kindn of liorina find tlioir way into tho 
 labia majora, tlio (inferior or iiii/Kiiio-lahidl and tho 
 f^oxtcrior or rfajino-lahitd. 
 
 Tho in(ffii)i(>-l(ihi(il, or that kind corrospoiuling to an 
 inguiiud hernia in tho malo, in not uncommon. Tho 
 hornia comos out throujfh tho inguinal (wuuil, follows tho 
 round ligament, and tl(>s(U'nds into tho anterior part of tho 
 labium niajus. Tt may contain intestine, a portion of tho 
 mesentery or omentum, an ovary, the bladder, or even tho 
 entire uterus. It may be mistaken for a tumor of the 
 round ligament or a hydrocele, or for an abscess, cyst, or 
 tumor in the labium, but bj'^ paying att(>ntion to the 
 general rules laid down in tho surgery of hernia a 
 diagnosis may be readily made. 
 
 Trcdfrncnf. A properly fitting truss will very often 
 give the required relief, but the wearing of it is 
 occasionally uncomfortable or irksome to the patient. 
 This class of hornia is particularly suitable for what is 
 commonly known as tho radicxil opcratiou, and Bassini s 
 method, modified so as to apply to the female inguinal 
 canal, is very readily performed and gives excellent results. 
 In cases where the opening is large or direct, buried 
 silkworm sutures, uniting the conjoined tendon with the 
 deep i^art of Poupart's ligament, will give the necessary 
 and -permanent support, acting in the same manner as 
 silk worm sutures when buried in the aponeurosis, after 
 CGiliotomy, to prevent ventral hernia. 
 
 Va<lino-l(ibi(il is a much rarer form of hernia. The 
 escaping abdominal viscera descend in front of the uterus, 
 along the vagina and bladder, between them aiul the 
 levator ani muscle, and form a swelling at the posterior 
 
DISEASliS OF Tllli VULVA. 135 
 
 (mhI of tli(< lahiimi tnnjiiH. It uHimlly contni h n part of 
 till' Hiimll iritcHtiric. 
 
 Troihticnf. It is ditfiiMilt to hold this form of luTiiia 
 back, but, aH it may bccomii very lar^v tho attempt h1iou1(1 
 be madt' with vaginal iM^HHarioH or iiitlatablc rubber ba^H. 
 
 Hydrocele cousiHts in a colhu^tion of tiuid iu that pjirt 
 of tho routid ligament wliic^h lies in or below tlu> iuj^uiiuil 
 canal. Thin Huid may be (-oiitaiiied in the proiu'SH of 
 peritoneum which at times surrounds the ligament outside 
 the internal inj^uinal ring (canal of Nuck), and in this 
 way may communit^ate with the ab(h)minal cavity; it 
 may bo in the surrounding connective tissue, or in the liga- 
 ment itself. Great care should be observed in making a 
 diagnosis of this rare malady. The sensi> of fluctuation, 
 with entire abseiu^e of symptoms of iiiHamnuition. tlu^ 
 absence of resonance on percussion or other signs of 
 hernia, the existence of translucency, and the gradual 
 development of the tumor without pain or constitutioiuil 
 excitement, \k'ould be reasons for suspecting it. 
 
 Trciihucni. It is unsafe to inject these tumors, the 
 same as in the nmle, on account of the uncertainty of the 
 diagnosis. By open incision the diagnosis may be properly 
 made and appropriate treatment i)ursued. The incision 
 is made over tlu^ tumor iu its long axis, the sac opened 
 and the contents carefully examined. After the fluid has 
 been evacuated the wall may be touched over with strong 
 carbolic acid, the cavity packed with iodoform gauze and 
 allowe i to heal by granulation. Should the sac communi- 
 cate with the general peritoneal cavity, it shouUI be drawn 
 down and closed off by a circular catgut ligature, or by 
 one if the methods recommended for the radical cure of 
 hernia. 
 
 Haematocele of the canal of Nuck and haematoma 
 of the round ligament are ev(m more rare than hydrocele. 
 The former consists of a collection of blood within the 
 process of peritoneum, and the latter in the interior of the 
 
L% MEDICAL AND SURGIC\L QYN/ECOLOOY. 
 
 round lij^amciit, nn tlu^y lit^ in tin* hiKuiiml canal. Tliry 
 may b(» dia^iioHi'd from intoHtiiial lu-rnia by tlic poiiitn 
 ri'ferrod to wluui Hpcakhig of liydrocelo, and from lirrida 
 of tho ovnry by its immobility and abHonce of Hensitivc- 
 ncHH. The trontmi'ut couHiHts in makinj^ an incision into 
 it, turning out tho contontH and packing with iodoform 
 
 gaU 7A\ 
 
 Injuries. Tho vulva may bo tho scat of bruiHos or 
 wounds in conHocpKuico of a fall upon some blunt or sharp 
 instrument, or from blows or kicks, which, if slight, readily 
 respond to ordinary treatment. Sliouhl tlu^ injury bo so 
 localized or of such violence as to injure tho reticulated 
 plexus of large veins, known as tlie bulbs of tho vestibule, 
 on(^ of two effects will be produced. If there be corres- 
 ponding rupture of tho skin a free and sometimes 
 alarming hemorrhage will occur, known as pudenddl 
 lu'morrlKiyc. If the skin remains intact, the blood pouring 
 out into the areolar tissue surrounding tho wounded plexus 
 will soon form a (\oagulum, constituting a bloody tumor 
 which has received tho name of pmlcniUil luriiKifocch'. 
 
 Cduscs. Tho j)r<'(lisj><tsin(/ cduscs are pregnancy, 
 varicose condition of tho veins, and largo pelvic tumors; 
 the oxciting causes are muscular efforts, blows, or incised 
 or i)unctured wounds. In pudcMidal hemorrhage a physical 
 oxamiimtion will at once reveal the condition, and the 
 control of the How will not bo difficult if managed on the 
 general i)rinciplos laid down for the treatment of hem- 
 orrhage. The clotted blood which forms a pudendal 
 ' ^Mnatocele may occupy the tissue of one labium or tho 
 ar tissue immediately surrounding tho wall of the 
 
 <ina. When a considerable sized vessel has been 
 raptured tho tumor may reach tho size of an orange; at 
 other times it is quite small, perhaps not larger than a 
 walnut. Care must be observed not to confound it with 
 abscess, pudendal hernia, inflammation of the vulvo- 
 vaginal glands, or oedema. The physical characteristics, 
 
DISEASES OF THE Vl'LVA. 137 
 
 niodi^ of (l(>v(»lof)m('(it. and ratioiml hIj^iik of hucIi affcctionH 
 nro HO (liffcmiit from i)U(lcii(lal liu'inatorrli' that a careful 
 oxainiiiatioii will always scttk* tlu- [)oitit with certainty. 
 
 Xntnral ronrm' (iftrt'fnnndfioii. Should the tumor bo 
 left to itself, it may bo absorbed in a short time; in five 
 or six days it may burst and discharge; the clot may 
 become encysted and remain in(letinit(>ly; or it may 
 creatt^ suppurative inflammation and formation of an 
 abscess. 
 
 Trcdfnicnf. A small tumor may be let alone, or treated 
 V ith a cooling astrinj^ent or absorbent application. When 
 the tumor is large, or experiment has demonstrated that it 
 will not undergo absorption, it is advisable to make an 
 incision into it antl evacuate the cont(>nts. If bleeding 
 points appear they may be securcnl by forcipressur(>, and 
 the cavity afterwards i)acked with iodoform gauze. When 
 the cavity is large, or the hemorrhage abundant, buried 
 catgut sutun^s may bo inserted through the walls of the 
 tumor so as to include the veins from which the hem- 
 orrhage occurs. After approximation of the walls by 
 these ligatures, and a gauze drain introduced, super- 
 ficial sutures may be inserted in the marginal mucous 
 membrane. As soon as pus is formed, whether largo or 
 small, it must at once be evacuated, the cavity carefully 
 washed out with bicldoride SC' ition and drained with 
 strips of iodoform gauze. 
 
 Phlegmonous inflammation. The areolar tissue of 
 the labia raajora is frequeiitly the seat of inflammation 
 and abscess. The disease is excited by irritating vaginal 
 secretions, vulvitis, direct injury, ami the peculiar blood 
 state which results in the development of furuncles and 
 carbuncles. 
 
 Didf/nosis. It is usually easy to distinguish this 
 disease, but care must be taken to diagnose it from hernia 
 of the intestine or ovary, and from haimatocole. ojdema, 
 and vulvitis. The ordinary symptoms of inflammation 
 
138 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 and tlu> ox(iuisit(^ sensitiveness of the swelling will servo 
 as a valuable aid. 
 
 Treatment. The first stag(> is best managed by cold sed- 
 ative and astringent applications, such as acetate of lead 
 and opium lotion. If suppuration is inevitable it should 
 be met by hot fomentations and hot bio^'loride absorbent 
 cotton poultic(>s. Early evacuation of the pus as possible, 
 is advisable, becausi^ the tissues obstinately resist natural 
 evacuation^ and the accumulation of pus is liktly to point 
 in another direction. 
 
 Cysts and abscesses of the vulvo-vaginal glands. 
 The long exert tory ducts of these glands, situated on each 
 side of the ostium vagiuiu between the vagina and the 
 ascending branch of the ischium, sometimes become 
 occluded by adhesive inflammation arising from acrid 
 dischargi^s, from the presence of pruritis from other 
 irritating causes. As a result, the secretion of these 
 glands is retained; they undergo great enlargement and 
 distension with or without preliminary formation of a 
 cyst; suppurative inflammation may be sot up and abscess 
 result. 
 
 Diajjiiosis. When cystic distension exists, the locality 
 of the round or ovoid mass rolling slightly under the 
 finger, without tenderness, will assist in making a diag- 
 nosis. Pudendal hernia and hydrocele of the round 
 ligament are two important conditions from which they 
 must be diagnosed. Hernia is reduceable and gives a 
 distinct impulse when the patient is requested to cough, 
 and it does not feel so elastic as in the case of cysts. Cysts 
 grow slowly, the percussion sound is dull, whereas the 
 appearance of a hernia is rather sudden and, if an 
 enterocele, is resonant on percussion. When inflammation 
 has been set up there are the usual symptoms present, the 
 mouth of the duct is red. and the fing(>r press(>d over the 
 site of the gland will discover a hard, painful, and perhaps 
 fluctuating tumor, about the size of a small hen's egg. It 
 
DISEASES OF THE VULVA. 139 
 
 may bo known from plilej^inonous inflnmma^^ion of the 
 liibinin by its distinct globular and liniitod outlines the 
 t'ornuT affection bc^in^ diffuHc. 
 
 Trcdfnicitf. The cyst mav be incised within tlie free 
 edge of the hibiuni and, afte. vacuation of the contents, 
 the sac wii)ed out with tincture of iodine or a ten per cent, 
 solution of (chloride of .Jnc, and then i^acked with iodoform 
 ^auze. It is desirable to remove a portion of the sac wall 
 after having incised the cyst. This operation, although 
 tedious, is certain in its results, and is the best to follow 
 under ordinary circumstances. The total removal of the 
 cyst is often a difficult and sometimes bloody operation, 
 and hatl bc^tter not be attmnptt^d, unless prepared for such 
 emergencies. Pozzi recommends, after withdrawing the 
 contents, to distend the sac with warm paratine, and whe.i 
 hardened, to dissect the whole mass out. After the 
 removal of the sac, by whatever method employed, the 
 cavity is closed by a deep row of sutures placed through 
 the edges of the wound and passing down through the 
 bottom of the cavity, and a second row placed at iialf the 
 depth. After insertion they are to be tied in the order in 
 which they were placed. When inflammation sets in, it is 
 to be treated in the same way as for abscess of the labia, 
 and as soon as fluctuation is distinct the pus should be 
 evacuated by a long incision, the cavity irrigated with 
 bichloride solution and drained with iodoform gauze. 
 
 Tumors. The vulva is subject to the formation of n 
 variety of tumors. The condjilonKifa acnmlnafa or 
 pn})iUom<d<i may be due to gonorrheal irritation, or 
 simply to the hypenemia and discharge from the parts 
 occurring during a vulvo-vaginitis or normal pregnancy. 
 They are found chiefly on the labia minora, or at the 
 posterior commissure, and may extend more or less deeply 
 into the vagina. 
 
 The coiKli/lomafa hit<i, occurring on the iiisidi' of the 
 labia maiora, on the perineum, or around the anus, are 
 
14:0 MEDICAL AND SURGICAL GYN/ECOLOGY. 
 
 always due to syphilitic infection. The treatment of the 
 acuminate and pajiilloinatous varieties consists in cutting 
 them off witli curvt'd scissors, and touching their bases with 
 caustic or with the actual cauti^ry; or they may be 
 effectually removed by puncture with the negative electro- 
 lytic needle. Compresses soaked in the tincture of tliuga 
 occidentalis mixed with equal parts of water will, in some 
 cases, cause atrophy of these growths. 
 
 Liponid have their origin either in the labiiim majus 
 or in the mons veneris. They are rare, but when they 
 occur, sometimes attain large dimensions. 
 
 Mjioma, Jihronui, myxoma, and miral (/roii^fliH have 
 their origin ordinarily in the labium majus. Their 
 tendency is to grow in the direction of the least resistance, 
 and lience it is not unusual for them to bec^ome peduncu- 
 lated, and sometimes they reach as low as the knees. The 
 treatment of these tumors is surgical and, when operated 
 upon with care, is devoid of danger. 
 
 ElcplKUiti'dsiis vulv(V. This disease, seldom seen in 
 this country, may affect the entire vulva or only part of it. 
 Its location is generally on the labia majora. the clitoris, 
 and the nymplia\ Histologically, several varieties of 
 this disease occvr, but they have all one element 
 in common, namely, a change in the lymphatic cir- 
 culation, the lymph vessels being dilated and indurated 
 from the beginning. They have their origin from repeated 
 attacks of lymphangitis, which ultimately result in hyper- 
 plasia of the entire derma and subcutaneous connective 
 tissue. When inflammatory changes with new forma- 
 tions occur first in the papilhv*. the tumor strongly resembles 
 the large coalescing condylomata. The large tumors are 
 liable to extensive ulceration from local irritation, and the 
 warty forms may undiu'go malignant degeneration. 
 
 Tn'((tiii('iif. All medicinal treatment has thus far 
 failed; the same may be said of the galvanic current, 
 the only rational one being surgical. 
 
DISEASES OF THE VULVA. 141 
 
 Lupus, sarcoma and cancer are fortunately rare. Thoy 
 occur usually upon the labia minora or majora and spread 
 thence in various directions. The prognosis of cancer, 
 which is usually of the epitheliomatous variety, is 
 unfavorable, unless seen very early and completely extir- 
 pated. Sarcoma presents itself as a tumor springin^j^ from 
 either the labia majora, the labia minora, or the clitoris, 
 and is diagnosed mainly by its rapid growth and soft fe(4. 
 In cases of difficult diagnosis, resort should always bo 
 made to the microscope. 
 
 Neuromata are of more frequent occurrence, and are 
 either situated about tlie meatus or clitoris, or at the 
 posterior commissure. They are usually nodules, not 
 larger than a pea or bean, and exquisitely sensitive to the 
 touch. They should be removed by thorough deep 
 incision with scalpel or scissors. 
 
 Varicose tumors. Such tumors may occur in the 
 vulva as the result of pressure from a pathological or 
 physiological growth in the pelvis. The distended veins 
 are readily recogni/.ed, and can hardly be mistaken for 
 any other condition. In most cases they are connected 
 with pregixancy, but may occur independently of it. 
 They may burst spontaneously and if the skin holds, a 
 hiematoma is formed. If the! skin breaks, a serious if not 
 fatal hemorrhage may follow, especially when associated 
 with pregnancy, at which time they are often of large size. 
 
 Uretliral caruncle. Just at the edge of the meatus 
 urinarius, and sometimes along its wall for some distance, 
 little vascular tumors develop which render the c^anal very 
 irritable. They consist of hypertrophied papillfi\ are 
 extremely vascular, and are richly supplied with nerve 
 filaments, facts which account for two corresponding 
 clinical observations, nanu^ly, that they bleed very freely 
 and readily, and that they are almost as sensitive to the 
 touch as a neuroma. 
 
142 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 Sijmf)foms. Tho patient complains of pain, accom- 
 paniod often with hemorrhage during sexual inti^rcourse, 
 in passing urine, in walking, or by contact of the clothing. 
 Inspection shows at the meatus a florid vascular growth, 
 varying in size from that of a cherry stone to that of a 
 pigeon's egg. Sometimes, instead of one, quite a number 
 may be found of small size extending around the meatiis. 
 Care must be taken not to confound it with prolapsus 
 urc^thne. 
 
 Treatment. In single large caruncles an almost posi- 
 tive promise of relief may be held out from its removal by 
 means of the thermo-cautery. When a number of small 
 fungous growths surround the meatus and extend up the 
 urethra, cure is extremely difficult, as after their removal 
 the morbid process rapidly produces more. When the 
 urethra has been invaded it should be thoroughly stretched 
 and the growths brought into view, when they may be 
 removed by scissors, or scraped from their attachments by 
 a curette, after which their bases should be touched by 
 the thfmo-cautery. Special attention should be paid to 
 any disordered condition of the urine or disease of the 
 bladder. The nervous hyperi^sthesia engendered during 
 the growth of these tumors is apt to continue, and an 
 irritable condition of the urethra and neck of the bladder 
 are likely to follow for some time after their removal, 
 hence it is well to notify the patient of these probabilities. 
 
 Urethval venous (iiKjionia is a disease affecting the 
 urethro-vaginal tubercle, and occasionally the urethro- 
 vaginal wall. It sometimes attains a large size and pro- 
 jects between the labia. Absence of sensitiveness will 
 diagnose it from urethral caruncle, which it closely 
 resembles in apptmrance, but the treatmtnit is Identical 
 with that condition. 
 
 Prolapsus urethrse. This accident consists, when 
 acute, of prolapse of the urethral mucous membrane 
 alone, but if it is of long standing there will be in ad- 
 
DISEASES OP THE VULVA. 143 
 
 (litiou n i^roliferntion of tho uuderlyinpf coniioctivo tissue. 
 It is not nil uncommon condition, and may exist for some 
 time without symptoms, but usually it creates difficult and 
 painful micturition, pruritis vuIvjb and leucorrhceal dis- 
 charge. It may be confounded with urethral caruncle 
 and venous angioma, but can be recognis(ul by remember- 
 ing that it produces a projection which completely 
 encircles the meatus, while the former do so only in part. 
 Neither pain nor hemorrhage can be depeniled upon for 
 diagnosis, as prolapse may develop such symptoms very 
 dcicidedly. 
 
 Treat me nf. Acute cases may be treated by replacing 
 the protruding mass, and by the subsequent application 
 of hot wati>r, by rest in bed ani^ by efforts to previ^nt 
 rectal and vesical tenesmus during the evacuation of these 
 organs. Tannic acid, or other astringent bougies, may 
 be introdiiced into tiie urethra. These means failing, 
 recourse may be had to linear cauterization of the pro- 
 lapsed membrane by means of the thermo-cautery. Ex- 
 cision of the redundant tissue is frequently necessary and. 
 after removal witli the knife or scissors, the urethral 
 mucous miMubrane should be stitched to the margin of 
 the oritice with tine sutures. 
 
 VULVITIS. 
 
 Vulvitis is the name applied to inflammation of tho 
 skin and mucous membrane covering the vulva. It 
 appears in three different forms, simple, pHrident, and 
 follienlar. To this chissiflcation there has been added by 
 some, the i>lil<>(/iii(>ii(ms, venereal, and (/aiijirenoKs forms. 
 
 Simple vulvitis is by far the most common form of 
 inflammation. It is usually produced l)y the irritation of 
 acrid vaginal discharges, by the pn^sence of pediculi, or 
 by pruritis. The secretions from the inflamed surfaces 
 are usually of a serous, non-purulent character. The 
 diaf/nosis is made by the red eroded appearance of the 
 
144 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 vulva, which often exttmds down to the anus and to both 
 nates, especially in stout women. 
 
 Purulent vulvitis. This variety of the aft'ectiou may 
 be either a non-specific form or a true gonorrluea. It may 
 result from simple vulvitis, specific or simple vagiuitis» 
 uncleanliness, friction from exorcise, erui)tive disorders, 
 onanism, chemical irritants, or excessive venery. 
 
 Difupiosis. The parts are red, swoHon, hot, and at 
 first dry, but soon a free flow of pus takes place whicli 
 bathes the whole surface. In addition to thes'? signs of 
 active inflammation, superficial ulcers will be found 
 scattered over the parts att't^cted, and at times th>> inflam- 
 mation will extend to the submucous and subcutaneous 
 connective tissue, producing abscesses { ph!<'<))it()Hoiis 
 vulvitis), and in rare cases patches of membrane will be 
 seen adhering to them {(liplithcritic vulvitis). The glands 
 of Bartholin may be involved, leading to suppuration and 
 tlie formation of abscess. At times tlu' meatus uriiiarius 
 becomes affected, prodncing a reddish margin around it, 
 accompanied by* painful micturition, and a sensaticni of 
 heat and s(;alding. The pus which is discharged, ^^speci- 
 ally when specific, gives forth a disagrec^able odor, and 
 is exceedingly irritating when brought into contact with 
 other parts. 
 
 Follicular vulvitis. By this form of vulvitis is meant 
 inflammation of the muciparous, sebaceous, and piliferous 
 glands. In ordinary purulent vulvitis these, as component 
 parts of the diseased membrane, are implicated in the 
 morbid action, but sometimes the glands alone are 
 affected by disease, when the name follicular vulvitis or 
 vulvar folliculitis has boon applied. The causes are about 
 the same as those of purulent vulvitis, and the general 
 symptoms those of local inflammation, but it is diagnosed 
 by the peculiar appearance it gives to the vulva, the labia 
 majora and minora being studded with small round red 
 protuberances, from the size of a millet seed to that of a 
 
DISEASES OF THE VULVA. 
 
 145 
 
 hemp seed. Ofton n hnir comoH out from tho middle of 
 one of these elevatiouB, and from the opeuiufj; n drop of pus 
 may be pressed out. As a rule the inflamed follicle 
 bursts, and shrivels up, but exceptionally the disease ends 
 in induration and the production of small hard nodules, 
 
 DifKjnosis. The signs and symptoms are usually clear 
 enough, nevertheless it is sometimes difficult to distinguish 
 one variety from the other. It is especially important, 
 but often impossible, to 
 determine whether the in- 
 flammation present be of a 
 gonorrluual nature or not. 
 Th^^ history of the case is 
 generally wanting or mis- 
 leading, but the following 
 features may be looked 
 upon as important, not 
 only in making a diagnosis 
 of gonorrhuial vulvitis, but 
 of gonorrlnual infection in 
 organs beyonil : A purulent 
 discharge in the absence 
 of ulceration, erosion, or 
 malignant disease, associ- 
 ated with inflammation of 
 the urethral orifice, and 
 two bright red spots mark- 
 ing the orifice of the ducts of Bartholin's glands (macula 
 gonorrlueica); warty condylomata complicated with folli- 
 cular vaginitis; salpingo-perimetritis; sudden development 
 of infiammatory disea.se of the genital organs in a newly 
 married woman, which injunvs her healtli to a degree out 
 of all proportion to tlie local condition; habitual aborti(m; 
 sterility acquired after the birth of one child; ophthalmia 
 neonatorum; and especially the detection of the gono- 
 coccus. 
 
 Fin. 40. — FoUiciil.ir Vulvitis. 
 
146 MEDICAL AND SURdlOAL OYN;ECOLOGY. 
 
 Trndniciif. Propliylaxis consists in scrupulous ch^nn- 
 liiicss niid in tlio prcvt' itioii m\d removal of cvt^ry cftusc 
 liki^ly to pro(luct> it. In schools and institutions, it is of 
 jjjrcat importance that tach person should have her own 
 basin and towel. Sponges, as far as possible, are to be 
 avoided; certainly they shoidd not bo used in common. 
 In acute vulvitis the paiient slumld bo confintHl to bed 
 and the diet of a li^bt unstimulating character. She 
 shoulil sit for Hftel^n miiiuti's in a warm hip bath, to 
 which has boon added bi carbonate of soda or permang- 
 anate of potash, and after this a compress wet with liquor 
 jjlumbi subacetatis dilute, or a solution of boric acid 
 (2 per cent), or of salicy'ic acid (1 to (i(XX)). appli(5d 
 frecpiently. In tlu^ mon^ chronic form, astringent and 
 antiseptic applications will also he requin^d, such as 
 solutions of acetate of lead and opium, tannin, carbolic 
 acid (1 to (>0), sulphate of copper (1 per cent), corrosive 
 sublimate (1 to .'{aX)). 
 
 In chronic cases, particularly in the intertrigo of fat 
 women, dusting powdt^rs will bo found useful: 
 
 R. Boric acid, zinc oxid., aa. drams ii ; 
 Pulv. aiiiyii, drama iv ; 
 Pulv. rad. iridis Horeiitiiui', oz. i. M. 
 
 Ointments are indispensable in some cases, especially 
 when the surface has to be protected; 
 
 R. Zinc oxid., drams ii ; 
 Carbolic acid, dram ss ; 
 Va.seliii alb., oz. ii. M. 
 
 If there be much local irritation, thymol (2 per cent), 
 or cocaine (5 per cent), may be added. 
 
 In follicular vulvitis the pustules should be opened 
 and the parts fomented with an antiseptic compress. In 
 acute inflammation of Bartholin's glands, a warm sub- 
 limate compress should be constantly applii^d and, as soon 
 as the absci^ss shows any tendency to point, it should be 
 freely opened, well washed out and draininl with iodoform 
 gauze. 
 
DISEASES OP THE VULVA. 147 
 
 There is a vnrioty of vulvitis wliieh 1ms boon styled 
 (/(iHjircnoux. It bogins on the vulva as a white blister 
 which soon changt^H to an uleer; it nc^xt asHumeH a 
 diphtheritica aspect and becomes gangrenous. It is a disease, 
 however, almost entirt^ly confined to children. 
 
 Eruptive diseases. The skin and mucous membrane 
 making up the vulva may, like the same structures in 
 other parts, be affected by eruptive disorders of various 
 kinds. Tln^ following will include thosc^ most commonly 
 met with: 
 
 rnir{(/(> presents large scattered pai>ules, very irrita- 
 ing, and generally have their apices bereft of cuticle. 
 
 Liclirn shows more numerous papules resting upon a 
 
 thickened and somewhat indurated cutaneous base. For 
 
 such conditions the use of one of the following formuhe 
 
 often proves very serviceable : 
 
 R. Menthol, flrams ii ; 
 01. OlivH', dniins iv ; 
 Chloroform, (hum i ; 
 Lunoliiii, oz. ii. M. 
 
 Ft. ungueiitiim. 
 
 R. Acid Salicyl, dram s« ; 
 (Jreosote, gtt. xl ; 
 (ilycerini Amyli, oz. ili ; 
 Ltinoliiii, o/. i. M. 
 
 Ft. uiif^uentum. 
 
 Eczema producers a red heated surface, covered with 
 little vesicles which, breaking down, give forth a serous 
 fluid. Sometimes there are successive crops of vesicles, 
 and in many cases of diabetes and vesico-vaginal fistula ; 
 this affection constitutes an exceedingly annoying and 
 even painful complication. In the acute stage, cold or 
 warm compresses and subacetate of lead lotions are 
 generally all that is needed. When the discharge is 
 profuse and watery the surface should be powdered. In 
 more chronic cases Hebra's unguentum diachylum, white 
 precipitate ointment (grs. xx. to oz.), or the following, 
 will often prove very serviceable: 
 
 I 
 
148; MEDIdAL AND SUimiCJAL GYN^ECOLOOY. 
 
 11. Boric acid, drain i ; ' 
 
 I Mil I lib. acot. , {ffH. X ; 
 BiHtuiitli. .siibiiit, dram i ; 
 VaHcliii alb., oz. i. M. 
 
 Ft. iiiif,'iioiit. 
 
 The vulvn mny also bn tho scat of acnr, cri/thona, aiul 
 n'ifsijK'his, but as thc^Hc diHi-asi^H ottVr nothing piHuiliar in 
 this region tlioy aro to bo treated tho samo as in otht^r 
 parts. 
 
 Herpes pro(iciiit(i lis iH a mild inflammatory aff'oction, 
 consisting, as it doos in other parts, of vosiolos, or a group 
 of vesicles upon an inflamed base, their appoaraneo being 
 preceded by a burning and it(!hing sensation. Tho 
 vesicles soon rupture and form scabs or shallow ulcers, 
 each the size of a single vc^sicle. Sonu^tinu^s it is accom- 
 panied with much (inlema of the vulva and may lead to 
 enlarg(^ment of one or more of the inguinal glands. It may 
 be confounded with a cihancre in tho erosive stage, but 
 that has a deep, dull rod, ooj^jpory color, and its floor is 
 smooth and shiny, without the small granulations foend 
 in herpes. This disease is also apt to be confounded with 
 exr/ema, but tho latter has a tendency to spread at the 
 edgi^s, herpc^s appearing in successive crops. In tho early 
 stage a cooling sedative lotion will give much rolicsf, and 
 tho following ointment may be applied: 
 
 R. Menthol, drum i ; 
 01. Olivii', drams iii ; 
 Bismutli. Hubiiit, drams ii ; 
 Lanolihi, o/. ii. M. 
 
 Ft. unguent. 
 
 Pruritis Vulvae. This affection consists in irritability 
 of the nerves supplying the vulva which induces tho 
 most intense itching, and desire to scratch and rub the 
 parts. At first tho irritability and tendency to scratch 
 aro slight and give little annoyance, but tho disorder is 
 aggravated by the counter-irritation which it demands for 
 its relief. Tho itching is so extreme that it irresistibly 
 drives tho patient to scratch herself, anil by constant 
 
DISEA8EH OF THE VULVA. 
 
 14'.) 
 
 ropctition the nkin boromcs torulor, its iutvor HPnHitiv(>, 
 cxcorintioiiH and intlnmiiuitory coiiditioiis follow, all of 
 which conirihuti' to the morbid condilioii. The misery 
 produced ill Hiu^h (mihch cannot be I'xa^^erated; tlu' i)atient 
 Ih tormented night and day, WKrioty be(!omeH dintaHti^ful to 
 lier. and nhe j^ivoH way to dcHpondency and di^jn^Hsion. 
 The itt^iing iH j^enernlly intermittc^nt, in some (rawos 
 <)c(Mirrinj^ at nij^ht, and in others only at ct^rtain periods 
 of tlu^ day. It is not always confined to the vulvn, 
 the irritation often (extending up the vagina, to tlu^ anus, 
 and down th(^ thighs. Tlu^ pn^disposing causes nn\ 
 uterine, vaginal or urethral disease; pregnancy; liabits of 
 indolence, luxury or vi(u^; unch^aidiness; or over-exercise 
 in one of sedentary habits. In nearly ev(^ry instance of 
 pruritis one of the following conditions will b(* found to 
 exist as i\\v ap[)arent cause at U^ast: (/ontact of irritating 
 dlst^harges, such as from acute and chronic tMidometritis 
 and vaginitis, from the discharge of cancer, from incon- 
 tinence of urine, or from diabetes; local intiammation, 
 as vulvitis, urethritis, or vaginitis; local irritation, as 
 eruptions of the vulva, animal parasites, f)nanism, vt^geta- 
 tions oTi th(> vulva, or vascular urethral c^aruncles. How- 
 ever produced, very soon secondary influences arisiiig from 
 excoriations, ulcerations, increased discharges, the result 
 of scratching, superadd themselves as auxiliary agents 
 and keep up the disorder. ■ 
 
 Trcdfimmt. The first effort must be made to discover 
 the disease of which the pruritis is a symptom, and 
 remove it by appropriate means. But this alone will not 
 be sufficient, for, while eradication of the mischief is being 
 attempted, palliative means must be vigorously adopted 
 for the sake of i^resent relief. Perfect cleanliness should 
 be secured by means of three or four sitz baths daily and 
 the vagina syringed with pure or medicated water. The 
 irritated surfaces should be protected by unctious sub- 
 stances or inert powders, such as bismuth or zinc oxide, 
 
lt«! 
 
 150 MEliU'AL ANU SUKOICAL UYNJiCULOUy. 
 
 combiiiod with lycoiKMlium or stureh. In cnm^ tlio (IIh- 
 
 clmr^c* conu'H from tht^ utc^ruH, uftcr a thorough viij^iiiul 
 
 (louflic, tlu' ii|t|)('r (>ii(l oF tlu' vaj^iiui slh)ul(l hv tanipoiu'il 
 
 with cotton luoiHtt'iu'd witli ii wt>ak Huj^arof lead or horairic; 
 
 Holutioii. If it is thci roHuit of a hx^al iiitiaininatioii it 
 
 Hhould bo trt^atod as olHowliorc rcoomiiuMidw! for such 
 
 conditions. Tcnipo'-ary ndi(^f (^an be obtained by covering 
 
 the parts with a lotion composed of the following: 
 
 R. Plumb, licet., (Irainn Ihh ; 
 Afitl Carbolic, dram i ; 
 Tiii(!t. Opii, o/. i ; 
 A(iii!i' ad., oz. xvi. M. 
 
 R. Hydra;;, bichlor., grs. xvi ; 
 Tiiict. Opii, oz. i ; 
 Atjuji' ad., oz. xvi. M. 
 
 Relief may also be obtained by a strong solution of 
 
 bromide of potash, or by painting the parts several times a 
 
 day with glycerine mixed with chloroform or acid hydro- 
 
 vjyan. dil. (1 to 8), or with morphim^ (3 grs. to the oz.), or 
 
 at longer intervals with a ten per cent acpieous solution of 
 
 cootane. Ointments often give markc^d relief, such as: 
 
 R. Chloral. Camphor, aa., drum i; 
 Vawolin alb., oz. ii. M. 
 
 R. Aciid hydrocyan. dil., ilrams ii; 
 I'lumbi acet., grs. xl ; 
 Olei cacao, oz. ii. M. 
 
 R. Acid Tannic, dram ss; 
 Kxt. Belladonna', grs. x ; 
 Va.'ielin, oz. ii. M. 
 
 Hyperaesthesia of the vulva consists in an excessive 
 sensibility of the nerves supplying the mucous membrane 
 of some portion of the vulva. Sometimes it is confined 
 to the vestibule, at others to one labium majus, at others to 
 the meatus, while at other times they may all be simul- 
 taneously affected. It is not a true neuralgia, but an 
 abnormal sensitiveness of the nerves. There is no inflam- 
 matory action and examination reveals nothing; the 
 slightest friction, however, excites pain and nervousness 
 and any degree of pressure is absolutely intolerable. The 
 
DISEASliS (IF Tllli VULVA. 151 
 
 (liHonlcr is comparatively rare and the trcatniout of it 
 moHt iinsatisfactory. even coinijlctc {l^Htnictiou of tlio 
 mucous uicmhrani^ of the Hcusitivi^ area with caustics, or 
 its removal with tlu' knife, has failed to [)roduce a 
 pernianetit cure. 
 
 Kraurosis vulvae is a diseast' .-harai^teri/ed by a 
 pet^uliar atrophic shriiikiu;^ of the intt^j^umentH of the 
 tvxternnl genitals and perineum, ri^sultiiig in the oblitera- 
 tion of the normal folds. Tlu* tissues att'cu'tinl beconu* 
 dry, shrink, lose* their normal elasticity and become so 
 brittle tiuit tiu^ most (direful examiiuition may cause dei^p 
 fissure. Tlu* surfaci* assumes a whitish, maceratt^d, shiinn^ 
 nppenrance. This disease does iu)t yield to any rimKul} . 
 
 Coccygodynia. UiuU^r this name are united different 
 and i)artially unknown patholo^^ical (H)uditions. thi> com- 
 mon feature of wliic^h is intense pain at the coccyx, wheiu!o 
 it may radiatt* into the periiuMim, hips, uterus, or bladder. 
 Sonu'tinu'H there are palpable diseases or deformitit^s of tlu* 
 coccyx, such as caries, ankyh)sis. luxation, or abnormal 
 length. At other times it is combined with disease of the 
 uterus, ovaries, or rectum, whiU> in a third class it is of a 
 l)ur(*ly luniralgic nature. It is usually found in women 
 who have borne children, but it occurs alst) in virgins. . It 
 often appears after ted'ous labor, accompanied by rupture 
 and straining of tlu muscles nnd ligaments. It may bo 
 due to violence from without, as from kicks, falls, or other 
 injuries, while sometimes it appears to be due to a reflex 
 neurosis. Severe pain is felt on sitting, and it may be so 
 great that the patient can sit only on one half ^f the 
 nates, near the edge of the chair, and the jjain is aggra- 
 vated in sitting down or getting up. The condition is 
 easily recognized by introducing the index fiager into the 
 rectum, while the thumb rests on the skin over the coccyx. 
 The slightest movement causes severe pain and f ometimes 
 it may be possible to feel the diseased coiulition of the 
 bone. 
 
152 MEDKiAL AND SURGICAL GYN.ECOLOGY. 
 
 Trcdfmnit. B(>foro any plan of troatmi^nt is adopted 
 care nuist bo tnki'ii to discovc^r wlicthcr the disorder is 
 secondary to uterine diseas(> or anal Hssure. Ifsnt^h should 
 be the easi% thi' primary disordt^rs and not thi^ir results 
 shoidd receive attention. If the disease be primary, 
 blisteriiij^. hypodermatic injections of morphia and the 
 persistent use of the galvanic current will often effect a cure. 
 While they are bein^ employed, tliree grain iodoform rectal 
 suppositories may be used, together with general treat- 
 ment to improve the nervous system. Sliouhl these means 
 do no good, resort must be had to one of the radical 
 methods for cure. The first operation consists in making 
 an incision down upon the coccyx, lifting the exposed 
 extremity of this bone, and then with a pair of scissors 
 severing the muscles. It has been recommended to 
 perform the operation subcutaneously, with an ordinary 
 tenotomy knife, but it is by no means so easy a matter as 
 one would suppose, besides, open incision clears up any 
 doubt there may be in the diagnosis and, if found 
 necessary, leads to the performance of the second method, 
 which consists of the complete severance of all attach- 
 ments, and the removal of the whole coccj^x, by a pair of 
 bone forceps, or by disarticulation with the kni'le. 
 
 CHAPTER XV. 
 
 LESIONS OF THE PELVIC FLOOR. 
 
 The pelvic floor, also known by the somewlnit in- 
 definite name of perineum, comprises the tissues which 
 together occupy the space between the bones of the jielvic 
 i)utlet. It is composed of a pair of broad thin muscles 
 (levatores ani), which are the chief support of tlu^ pelvic 
 viscera, and an arrangement of fascise and muscles, the 
 components of which act as accessories. Until very 
 
LESIONS OF THE PELVIC FLOOR. 15,'j 
 
 rooontly tho porinoum was considoriHl ns n thick wcdjifo- 
 slinpcd body, (K^sigiuiti'd as tlio "poriiical body," wliicli, 
 acting as an inverted koyntone of an arch, 'nati^ialiy 
 aided in the support of the uterus. It is now more 
 accurately regarded as a movefible centre of attachment 
 for the muscles and pelvic fascia; which enti^r into the 
 formation of tlie pelvic floor, as w(dl as for tlu' attachmc^it 
 of the lower portion of the rectum and vagina. By a 
 study of its anatomy and the resiilt produced by the more 
 or less complete laceration of it, its functions can be more 
 readily estimated. Briefly, it may be said to assist in 
 sustaining the anti^rior wall of the rectum, preventing a 
 prolapse of this canal, which, should it occur, would havi^ 
 a tendency to drag down the upper vaginal concavity and 
 destroy the equilibrium of the uterus. In the same way 
 it assists in sustaining the posterior vaginal wall which 
 otherwise would allow of a rectocele. The anterior 
 vaginal wall, and with it the bladder, is in part supported 
 by the posterior vaginal wall, and a sagging of this would 
 tend to the production of a cystocele. If affords by its 
 presence in the act of defecation counter-pressure, by 
 which the focal mass is turned br, "kward to follow the 
 curve of the canal, before it is ejected. The perineum 
 may lose its tonicity or efficiency from the following 
 causes : — 
 
 1. CoiistitntioiKil fcchlrncss. In girls of weak deli- 
 cate flbre, the pi^rineum will, without any assignable cause, 
 be found incapable of performing.; its functions. Such 
 cases are not commondy met with, but when they occur, 
 the examining finger reveals not only abnormal relaxation 
 of the perineum, but of the vaginal walls as well. 
 
 2. Fcchlcnci^s. flic result of proloiij/cd orcr (listciisioii. 
 When a prolapsed uterus remains for a long time betwinui 
 the labia, the perineum, by over distension, loses its 
 power, and, after restoration of the uterus, remains per- 
 manently enfeebled. This condition is likewise produced 
 
 11 
 
154 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 by the proHcnco of largo fibrous polypi, or by the wearing 
 of Inrgo globular pessaries. 
 
 3. Siihinroliifioii. During utero-gostation the perineum 
 undergoes physiological hypertrophy, which continues 
 until delivery. Involution may fail to take place, and it 
 will thus remain large, lax, and wanting in contractile 
 power. Subinvolution often affects the vagina and 
 perineum simultaneously, and, as a result, the anterior 
 vaginal wall and bladder sag downward for want of 
 support, and the posterior vaginal wall and rectum pro- 
 trude over the ineffectual perineal barrier. 
 
 •4. Senile atrophi/. Complete uterine jirolapse is by 
 no means rare in old women. As the decadence of 
 advancing years shows itself, the perineum, hitherto 
 strong, becomes inefficient and inactive. 
 
 5. Ldcevdtion. Injuries due to the passage! of the 
 child during labor are exceedingly common, and a large 
 proportion of female diseases take their origin thus. 
 Rupture of the perineum furnishes one of the most fruit- 
 ful sources for the absorption of septic elements; and 
 thousands of women suffer throughout their lives from 
 uterine displacements, (nigorg(Mnents. an<l vesical and 
 rectal prolapse, from injuries intiicted upon it during 
 parturition. 
 
 Presented thus to the intelligent obstetrician who has 
 familiarized himself with the anatomy and physiology of 
 the perineum, it is difficult to understand how there can 
 be any doubt of the propriety of early closure of a rup- 
 tured perineum, for should the operation prove a success, 
 the gain to the patient will be great; if it prove a failure, 
 no evil will have been done. 
 
 From what has been said it will be readily understood 
 that certain diseases, disordturs, or conditions are apt to bo 
 associated with, or to be the direct outcome of lesions of 
 the pelvic tloor. They may bo thus enumerated:— 
 
LESIONS OF THE PELVIC FLOOR. 
 
 155 
 
 1. Prolapse of the vagina. When the tono of the wall 
 of the vagina 1ms boon impaired and it ijonches into its 
 own canal, so as to fall downward toward the vulva, the 
 condition is called prolapsus. From a study of the 
 anatomical relations, it will be readily seen that prolapse 
 of the vagina, without simultaneous displacement of one 
 or more of its surrounding viscera, must be considered as 
 exceedingly rare, and that it must of necessity be asso- 
 ciated, to some extent, with rectocele, cystocele, or uterine 
 prolapse. Among the causes of prolajjse may be men- 
 tioned violent efforts of the abdominal muscles, repeated 
 parturition, senile atrophy, 
 rupture of the perineum, 
 previous distension by tu- 
 mors, and subinvolution of 
 the vagina and perineum. 
 The displacements may be 
 of two forms, acute, or 
 that form which comes on 
 as a r<'s-':ll of violent effort, 
 which, with great sudden- 
 ness, forces the contents of 
 the abdomen down upon 
 the pelvic viscera, and is 
 generally accompanied by 
 sudden descent of the uter- 
 us. The ordinary or chronic 
 form is that which, by slow 
 and steady action of one 
 
 or more of the causes enumerated, little by little forces 
 the folds of the vagina downward, toward or through 
 the vulva. 
 
 2. Ci/storele, or prolapse of the bladder, consists of 
 descent of the bladder toward the vulva, so as to impinge 
 upon the vaginal wall. When the anterior wall of the 
 vagina ceases to afford the required support, tlu^ bladder 
 
 ^^^iiff 
 
 Fig. 41. — Cystocele and Rectocele. 
 
ir)() MEDICAL AND SURCJICAL GYNECOLOGY. 
 
 descends and forms n siiihII poucli in the vagina, wliitth 
 gradually increases until it forms a de(!ided tumor and 
 protrudes between the labia. Residual urine retained in 
 this sjjecies of diverticulum decomposes, cystitis nud 
 vesical catarrh are established, all of which further annoy 
 the patient by the new set of symptoms pnxhiced. 
 
 3. Rccforcic, or prolapse of the rectum, occurs in a 
 similar manner, and the pouch thus formed soon becomes 
 filled with fecal matter. The feces becoming hard, and in 
 consecpience irritating, create mucous inflammation and 
 discharge, accompanied by tenesmus, obstinate constipa- 
 tion, and hemorrhoids. 
 
 4. Eiifcrocc'lc, or prolapse of the intestine, consists in 
 descent of a portion of the small intestine into the pelvis, 
 so as to encroach upon the vaginal canal. Loops of 
 intestine, finding their way to the bottom of Douglas' 
 pouch, gradually stretch this serous prolongation and, 
 advancing between the rectum and vagina, push the 
 posterior wall of the latter before it so as to form a tumor 
 at the vulva. 
 
 Treatment. Should the accident have occurred sud- 
 deidy, reduction should at once be accomplished, and the 
 recurrence of displacement prevented by appropriate 
 means. Sudtlen cases of vaginal prolapse, cystocele or 
 rectocele are, however, very rarely met with, and it is 
 mostly those which have slowly and gradually established 
 themselves that demand treatment. 
 
 The methods adopted for overcoming such cases are: — 
 
 1. By the use of loral astriiigeiit^i and by the persistent 
 insertion of minlicated astringent tampons. These 
 methods will often restore the tone of the vaginal walls 
 and bring about a complete cure, but they can only be 
 effectual in slight cases; in those of graver character they 
 will prove iusuflicient. 
 
 2. By st(pf)lewentai'j) unpports. Numberless forms of 
 special supports have been invented for the purpose of 
 
LESIONS OF THE PELVIC FLOOR. 157 
 
 ntfording relief, witli more or less success. The vaginal 
 pessary does little or no good here. In many cases no 
 pessary which rests upon the walls of the vagina can be 
 retained within the distended canal; in others none can 
 be found capable of resisting the downward pressure; 
 while in all, increase of dilatation and atony is affected 
 by them. In some cases an exception will be found to 
 this rule in Cuttc^r's cup jjessary, or some similar instru- 
 ment, supiiorted by an external attachment. Gehrung's 
 pessary, while it does not cure cystocele, gives much 
 comfort to the jsatient, and may obviat(^ the necessity for 
 oi)eration, when such is considered inadvisable. 
 
 ii. By sHiujIcdl procedures. Of these there are three, 
 any one of which may prove effectual. If a ruptured 
 p(^rineum seems to produce the want of support, peri- 
 neorrhaphy may be all that will be necessary. Should 
 this not be sufficient, colporrhaphy should be performed 
 on the anterior or posterior vaginal wall, as one or the 
 other seems most at fault, and should tlu^ condition be 
 still furtlua* aggravated, an anterior colporrhaphy and 
 posterior colpo-pi^inciorrhaphy may be resorted to, to 
 retain the prolapsed structures. 
 
 Colporrhaphy or elytrorrhaphy is an operation re- 
 sorted to with the idea of constricting the vagina so as to 
 diminish its calibre and, by this means, remove the 
 traction exerted by its fall upon the rectum, blackler and 
 uterus. 
 
 Anterior colporrhaphy. Hims' iii, "khL The patient 
 is placed in the dorsal position, and the knees sei)arated 
 by a Clover's crutch. A vulsellum is inserteid into 
 the anterior lip of the cervix; a tenaculum hooked 
 into the mucous membran(> of the anterior wall of the 
 vagina, just below the urc^thra, and a Sims' large speculum 
 introduced. Two tenacula an- next hooked in near the 
 lateral sulci, and the amount of tissue to be removed is 
 estimated by approximating them. By making a snip 
 
158 MEDICAL AND SURGICAL GYNiECOLOGY. 
 
 with n pair of scissors on encli side, the grontost width of 
 tlio surfnco to bo denuded inny be thus marked out. The 
 whf)ie surface to be pared is put on the stretch and, with a 
 pair of scissors curved on the flat, a strip of mucous 
 membrane, about one-third of an inch wide, is raised in 
 the form of the letter "V," the apex being just below the 
 ur(>thrn. the arms passing up on each side so as to 
 includi^ within them the amount of redundant tissue. 
 
 Fit;. 42. — Clover's Crutch. 
 
 Tlie two extremities of the arms pass back laterally as far 
 as the cervix, and by a removal of additional strips of 
 mucous membrane at right angles to the extremities of 
 the arms, they are made to approximate each other in 
 front of the cervix. Commencing at the apex of the 
 triangle, catgut or silkworm sutures are passed beneath 
 the denuded surface on one side, and then crossed over 
 and passed beneath the denuded surface on the other side. 
 After insertion the lateral denuded surfaces are approxi- 
 mated and the ligatures tied, care being taken in this, as 
 well as in all similar operations, not to draw the sutures 
 too tight lest they cut their way out. 
 
 Hrujar makes his denuded surface in the form of a 
 lozenge or rough ellipse, with the long diameter in the 
 long axis of the vagina, and advises the excision of all the 
 redundant anterior wall. Closure of the wound may be 
 
LESIONS OF THE PELVIC FLOOR. 
 
 15<) 
 
 carried out by through niid through sutiiros of silkworm 
 passed beneath the denuded surfaces, or by means of 
 deep and superficial layers of iuterruptt^d sutures, or by 
 two or more layers of superimposed continuous sutures. 
 
 Stoltz''s iiif'f/tod consists in making a circular denuda- 
 tion, embracing the larger portion of the prolapsed vaginal 
 wall, and then passing a thick silk suture, witli a needle 
 at either end, just outside the edge of the wound, begin- 
 ning at the point nearest the cervix and emerging on either 
 side just below the meatus. The stitches are not entirely 
 buried, but are made to emerge and enter again at short 
 intervals, and when the denuded portion has been pushed 
 up they are crossed and carefully tied. 
 
 Lcfo rPs opcrntion 
 consists in dcniuding an 
 elongated quadrangular 
 surface on the anterior 
 and ijosterior surfaces of 
 the prolajjsed vaginal 
 walls, and then uniting 
 them by sutures, replac- 
 ing the uterus as the 
 sutures are tied. It is 
 obvious that this oper- 
 ation can only be select- 
 ed for patients of ad- 
 vanced age, or for those 
 who have ceased to men- 
 struate. 
 
 Posterior colporrha- 
 phy consists in the de- 
 nudation of an elliptical surface on the posterior wall, 
 similar to that described, but it is seldom resorted to 
 alone, When indicated, it is generally combined with 
 perineorrhaphy, forming the operation known as colpo- 
 perineorrhaphy. 
 
 Fic. 43. — Stoltz's operation for cystocle and 
 Hegar's operation for rectocele. 
 
Kit) MEDICAL AND SURGICAL OYN^COLOCiY. 
 
 PERINEORRHAPHY. 
 
 By this term is monnt rostorntioii of tho porinoum. 
 Tliis oporntivo procodurc is not limited to tlu> euro of 
 Incoratioii tho rosult of parturition, but is npproprinto to 
 tho restorntiou of n porinoum which has k)st its power 
 and functions from any of tho causes previously men- 
 tioned, and when porformt^l for such is to be conducted 
 upon exactly the same principles as those which apply 
 to the operation for laceration, 
 
 Varieties of laceration. In its simplest form tho 
 ln(H^ration extends through the mucous mombraiio of the 
 vagina, the integument, and tho junction of the bulbo- 
 cavernosus with the transversus perinei muscles, as well 
 as through a few fibres of the levator ani and correspond- 
 ing fascia?. It may be more extensive, and prolonged I 
 backwards, so as to involve tho structures as far as tlie 
 sphincter. Those forms have boon designated as hicom- 
 })l('f<' rupture. Tho rupture may extend througli the 
 sphincter ani, to which the i -.mo complete 7'upt\irc has 
 been given; or it may extend still farther and involve 
 more or less the recto-vaginal septum. Instead of any of 
 tlu>so, the laceration may be a subcutaneous separation of 
 i\\v, muscles of tho pelvic floor, at, or near their junction in 
 tho median lino. The evils resulting from partial rupture 
 are by no means insignificant, but they are more tolerable 
 than those which follow complete rupture. When the 
 sphincter ani is torn through, and still more markedly when 
 the rectal wall is ruptured, incontinence of feces and rectal 
 gasc^s occur to such an extent as to embitter the life of tho 
 patient. 
 
 The consequences of rupture of the perineum may 
 thus be presented: Subinvolution of the vagina, prolapsus 
 vaginio with cystocele or rectocele, prolapsus uteri, incon- 
 tinence of feces and prolapsus recti. It is the oi^inion of 
 many that a laceration which does sever the sphincter 
 may unite witiiout surgical treatment, but it is doubtful 
 
LESIONS OF THE PELVIC FLOOR. 
 
 1<)1 
 
 if comploto rostorntion ever occurs by iinmcdinto union. 
 Repair is occnsionnlly effected by grnnulation, and often 
 is very efficient, but never perfect, on account of th(^ 
 tendency to formation of unnatural adhesions, cicatricial 
 bands, and cicatricial tissues, with the consequent con- 
 tractions, retractions, d'stortions and indurations. 
 
 Operation for incomplete rupture. The patient is 
 placed on the operating table in the dorsal position, the 
 legs being held apart by Clover's crutch. The first 
 part of the operation 
 consists in denuding 
 the surfaces to be 
 united, the extent to 
 which this should 
 be carried on de- 
 pending upon the 
 extent of injury, and 
 tlu^ amount of pro- 
 lajjse of the vaginal 
 wall. A point is 
 marked on each 
 side as high as the 
 denudation should 
 extend, the seat of 
 the highest caruncu- 
 la myrtiformis often 
 serving as a good 
 guide. Grasping the 
 tissue at one point 
 with a pair of tissue 
 forceps, scissors are 
 made to remove a 
 
 strip, at the junction of the skin and mucous membrane, 
 from this point to a corresponding one on the op- 
 l)osito side. In a similar manner a strip higher up is 
 removed, and so on until a sufficient surface has been 
 
 Fi<;. 44. — Operation for Incomplete laceration of the 
 perineum. Denntlation completed, and sutures 
 in the recto-vaginal septum introduced. 
 
162 
 
 MEDICAL AND SUIUilCAL tlYN/ECOLCKlY. 
 
 (ItMiudi'd. The (liHtnnco to which tliiH should b(^ oarric^l 
 up will dopiMid upon tho oxteiit mid ttluiractcr of thu 
 injury. If thero is no prolapso of th(^ pelvic floor, or of the 
 posterior vnginnl wall, it will suffice to denude the surface 
 as far as the original laceration only, otherwise it may be 
 necessary to carry the denudation high up on the vaginal 
 wall. 
 
 H('morrli(i(/(' can generally be controlled by si)onges 
 and hot water. If there is any decided spurting it may 
 
 be checked by a 
 light pinch with 
 hemoBtatic forceps, 
 or by the temporary 
 introduction of a 
 ligature until the 
 I jiiLlMBiili'L " °°W 11- sutures are intro- 
 
 r M?m^-. ir M / duced and tied, when 
 
 all hemorrhage will 
 then be brought 
 under control. Com- 
 mencing in the up- 
 per angles of the 
 denuded surface 
 which point toward, 
 or lie in the lateral 
 sulci, sutures are in- 
 serted on each side. 
 After these have been placed, a silkworm suture, threaded 
 on a good sized, full-curved needle, is inserted through 
 the skin, at the poinl where denudation was first started, 
 and passed outward deep into the tissues. It is then 
 curved round in the tissues in front of the rectum, then 
 deep into the tissues on the other side, and made to emerge 
 at a point corresponding to the one where it was entered. 
 If there is any difficulty in making the needle follow this 
 extensive curve, it may be brought out in the median line 
 
 Fig. 45.— Operation for lacer.ition of the perineum and 
 sphincter ani. Denudation complete. 
 
LESIONS OF THE PELVIC FLOOR. 163 
 
 nnd ro-iiiftortod. Tho noxt suturo is inserted in tho snmo 
 way, about tlircc-ci^litlis of an inc^li ncunT the anus, and so 
 on with tho third and fourtli, until thi^ posti^rior anglo of 
 tho wound has boon roachod. Tho catgut suti'-os first 
 introducod within tho vagina aro now tied and cut short. 
 Noxt in ordor, tho first silkworm sutun* is brought up, 
 and, when tiod, unitos tlio highest points of tho lateral 
 odgos of tho denuded surface, and now forms tho now 
 posterior c jmmissure. Tho remaining sutures aro next 
 tied in ordor, and the wound drossod with borated 
 iodoform powder and with strips of iodoform gauze laid 
 over tho vaginal and perineal sutures, after which a pad 
 and " T " bandage aro applied. It will probably bo 
 necessary to cathotorizo the patient every six hours for a 
 d"y or two, after that slu> usually can pass tho urine 
 voluntarily. On tho second evening a mild laxative may 
 bo given and a soap and water enema the next morning, 
 after which the bowels should be moved daily with an 
 enema. Tho external sutures may be removed on the 
 ninth day and tho patient allowed up at the end of two 
 weeks. 
 
 Operation for complete laceration. The two varieties, 
 laceration of the sxjhincter ani alone, and tliat involving 
 the recto-vaginal septum as well, may conveniently bo 
 considered together. If the bowel be not injured above 
 an inch and a half from the sphincter, one operation will 
 suffice, but if it extends far up, it is better to close it by a 
 primary operation, consisting of vivifying its edges and 
 uniting them. When tho sijhincter ani has been ruptured, 
 the severed ends are drawn outward and backward by the 
 retraction of the muscles, until they lie on either side 
 nearly on a line with tho posterior walls of the rectum, 
 and are often easily recognised by a pitting or depression 
 at these points. Tho process of denudation should bo 
 begun by seizing the end of the musck^ on one side, and 
 with scissors exciso a strip of tissue, so as to free the torn 
 
164 
 
 MEDK'AL AND SUR(HOAL (lYN-ECOLOOY. 
 
 cud of tlu' muHcl(>. From tlioro it in to bo cnrriod forwnrd 
 and inward across the brid^'c formed by tlie recto-vaginal 
 Hcptum, cutting away all cicatric^ial tissue fouiul in it, 
 after which the denudation is to be continued down the 
 opposite side, so as to expose the torn end of the sphinct(^r 
 there. After this, the denudation is carried upward upon 
 
 each side to the poiiit 
 where the laceration be- 
 ^an, or even higher, if 
 there is much relaxation 
 of the rectal and vaginal 
 walls. At this stage of 
 the vivifying there are 
 two broad denuded sur- 
 faces, one on each sid(\ 
 connected by an isthmus 
 formed by the rt^cto-vag- 
 inal septum. When the 
 recto- vaghial wall has 
 been iir. olved for a short 
 distanct^ catgut sutures 
 ar(^ to be insi'rted from 
 the rectal side, tlu^ lugh- 
 est one first, and, by 
 
 F'r<;. 46.— Complete laceration iif perineum extend- <■ i c 
 
 ing into recto vagin.\l septum. Denudation meailS ot them, Carcrully 
 complete, and recto-vaginal sutures inserted. , . 
 
 coaptate their denuded 
 surfaces. Care must in every case be taken to properly 
 unite the denuded ends of the sphincter. For this 
 purpose a silkworm suture or braided silk is to be inserted 
 a quarter of an inch behind and inside the end of the 
 retracted muscle, and carried under the denuded surfaces 
 parallel to the repaired rent in the septum, so as to unite 
 the innermost fibres. A second suture is inserted at tlu^ 
 outer end of the broken sphincter and carried around 
 parallel to the first, after which both are tied. A silkworm 
 suture is next entered at the highest lateral point of the 
 
LESIONS OF THE PELVIC FLOOR. 
 
 K)") 
 
 (UMMuliitioii, wlirn^ tlic iM^w rommiHHiirc is to Im^ formed, 
 and carried around after tlu> inaiiiicr dcHtTihcd for iiicom- 
 
 ^p.rr^ 
 
 'P^'t^rf/; 
 
 % 
 
 
 '.>--<i 
 
 m. 
 
 Fl<;. 47. — DiaKrnin of operation for 
 simple rupture. 
 
 Fig. 48.— Operation for complete 
 rupture. 
 
 ploto laceration, after which the remaiiid(T of the operation 
 is to be tinished in the manner already described. 
 
 Flap-splitting operation. The operation referred to 
 is tlmt introduced by Lnwson Tait, and recommended 
 after him by Saenger. After the patient has been placed 
 in the lithotomy position, the left index finger of the 
 operator is introduced into the rectum, a blade of a pair 
 of sharp-pointed scissors is inserted in the median line of 
 the perineum, where the cicatricial tissue meets the skin, 
 and is made to cut to the left in a curved line along this 
 margin, to the upper border of the perineal cicatrix. The 
 scissors are again inserted in the median line and made to 
 cut to the right, so that when complete the incision assumes 
 a "U" shape. The upper vaginal tlap is then drawn 
 upward, in front of the vestibule, by means of tissue 
 forceps, and the lower rectal flap downward, by similar 
 
166 
 
 MEDICAL AND SURGICAL GYN/ECOLOGY. 
 
 menus, increasing, if necessary, th's '>ow formed quadri- 
 laternl surface by splitting the septum farther up. A 
 curved needle, pushed through the skin, outside the 
 wound, at the anterior end of one incision, is made to pass 
 under the cut surface, and is so directed that it will pass 
 through, or just in front of the commissure formed by the 
 two flaps and emerge through the skin on the other side 
 at a point corresponding to the point of entrance. A 
 similar suture is inserted half an inch farther back, and 
 made to travere t the tissues of the rectal flap lower down. 
 
 Vn:. 49.— Flap-spHitiiig operaiicii for in- 
 complete l.icer.-ilion of the Derineiini. 
 Lines of incision. 
 
 I''n;. 50. - Flap-spliltinj; opei,.iion (ot 
 complete laceration of the perineum. 
 Lines of incision. 
 
 One or two more are similarly inserted farther back, 
 according to the size of the denuded surface. The first 
 ligature is then tightened, aft?r <-hit the remainder. 
 Instead of passing the sutujes through the skin, Tait 
 recommends their being passed ju.-st within the edge of 
 the wound. The almost inevitable puckering of the 
 vagintd flap is corrected, by short interrupted catgut 
 sutures passed froi- one mucous surface to the other, 
 through its w'ole w.'dth. 
 
LE.IIONS OF THE PELVIC FLOOR. 
 
 167 
 
 In complete laceration, tlio scissors are made to enter 
 the n '^o-vaginal septum forming the isthmus and, after 
 splitting it and making the anterior incisions, the scissors 
 are re-entered, and an outward and backward incision is 
 made on each side, so as to reach and denude the retracted 
 ends of the sphincter ani. The rent in the septum, if any, 
 together with the margins of the spliincter, are ai)proxi- 
 mated in tlie same manner as already described, after 
 which the sutures are introduced precisely as in the 
 incomplete form. 
 
 COLPO-PERINEORRHAPHY. 
 
 Hegar's operation. Incomplete rupture. As the 
 name implies, there are two parts to the operation, that 
 which narrows the vagina, 
 and that which api)roximates 
 the muscular fibres. Th 
 former is entirely intra- ^^^^U•j:^?x^-i' 
 vaginal, the latter partly 
 vaginal and partly perineal. 
 On each side, at points, h, c, 
 (Fig. 52), corresponding to 
 the original commissure, 
 ^lie mucous membrane is 
 caught up and nicked. 
 High up on the posterior 
 vaginal wall, above the rec- 
 tocele curve, a, a similar 
 mark is n\ade and the three 
 points united by lateral 
 linear incisions. Tiie apex 
 of the tr'-^ngle is seized, and 
 the flap dissected down to 
 the base of the triangle, he, 
 
 which forms the margin of the laceration, and there cut 
 oflF. Dee « buried catgut sutures, alterna' ing with super- 
 ficial ones, 1, 2, 3, 4, 5, 6, 7, 8, 9, passing through tl^e 
 
 ;. 5''.— Flnp-spliieinp o|)eration foi l.icer.-iled 
 perineum — Appearance of wound and in- 
 trtxUictioii of sutures. 
 
168 
 
 MEDICAL AND SURGICAL (lYN.ECOLOGY. 
 
 tlie niargitiK of the domulwl surface, are iiisertt^d 
 from above downward, whieli, wlieu tied, uuitt^, f<(. A 
 silkworm suture is carried up under tlie wound, from a 
 
 point a short distance from 
 the median line, //, to a point 
 near the closed lino, /, and 
 down to the corresponding 
 point on the other side. The 
 second suture is inserted 
 midway between the first 
 and tlu^ point, c, brought out 
 on the edge of the denuded 
 surface at, h, reinserted on 
 the other side at, /, and 
 brought out through the 
 skin at a point correspond- 
 ing to its entrance. The 
 last suture is inserted near, 
 c, brought out at, k, rein- 
 serted at, ,/, and brought out 
 through the skin near, /). 
 After being tied, a few su- 
 perficial sutures may be in- 
 serted to ensure coaptation. 
 Complete laceration. A 
 point is taken n* r, in the 
 median line, an inch ril:ove. 
 
 Fig. ,s2.— Heg.ir's Colpo-p.-rineorrhaphy : sii- f, (Fig. 53 \ the UJ>per pjillt 
 
 Hires s, 7, and g slant tlownwaril toward the . ' , . ' 
 
 entrance, and are hronglit mil about a quar- in tllC Tent lU tho VCCtO- 
 
 terofan inch from the median line ; />', the , _ 1 1 rn 
 
 triangle shown in .( having heen closed, the vaginal Wall. 1 WO otlierS, 
 
 perineal sutures are inserted — lo, alllniried; i i i i i i 
 
 II .anc 12, partly free-all in a slanting O, aild, O, locatcd at tlie loWCr 
 
 end of the labia, at points 
 where we desire the new commissure to be, are next marked 
 out. Commencing at, .r, a curved incision is mad(> along 
 the line, xnh, and then curved downward, along the line, 
 hdy to, (/, tho point indicating tho torn end of the sphincter. 
 
LESIONS OF THE PELVIC FLOOR. 
 
 IC/.) 
 
 KlG. 53. — Hegar's operation for complete 
 laceration of the perineum. 
 
 A similar incision is next mnde on tlu' otlu^r side ; the 
 points, (/, and, c, are carefully denuded and made to 
 communicate with each other by carrying the ilenudation 
 across the recto-vaginal septum, removing nil cicatricial 
 tissue there. The surface thus mapped out is finally 
 denuded. Sutures are inserted from side to side, under 
 the whole raw surface 
 represented by, .rmu. 
 Next the sutures in the 
 recto-vaginal wall, if 
 any are required, are 
 inserted, followed by 
 those for coaptating the 
 sphinctei', after the 
 manner already de- 
 scribed. Next the 
 lines, ma, and, nh, are 
 brought together by 
 deep catgut suturo^s, reaching half way under the raw 
 surface, and fairtlier coaptated by superficial ones. Finally 
 four or five silkworm sutures are placed rather superficially 
 on the perineal surface. 
 
 Emmet's operation. The top of the rectocelo, li, is 
 caught up with n tenaculum, and other tenacula are 
 inserted at the highest caruncula myrtiformis on each 
 side, T, Tl, (Fig. 54), while a fourth is inserted at the 
 median line, H, in front of tlie anus. By drawing in 
 divergent directions on all four tenacula at the same 
 time, a rhomboidal part of the mucous membrane of the 
 vagina is put moderately on the stretch, with two triangu- 
 lar-like Hurfaces, apex upward, extending outward and 
 upward in the lateral sulci of the vagina. The mucous 
 membrane is now removed from the "M" shapi'd space, 
 particular care being taken to go deep enough into th(> 
 sulci. The insertion of the sutures is begun at the upp(>r 
 angle of one side, passing them from the outside towards 
 
170 
 
 MEDICAL AND SURGICAL GYNiECOLOGY, 
 
 the nicdinn lino, not strniglit norosH, but first downwards 
 and inwards to the centre of tlio donndcd surface, and 
 tlien upwards and outwards through tlK> tongue of tlu^ 
 ct^ntral dap. A series of four or five of these sutures are 
 passed and at once tied. Having completed one triangle, 
 and the other treated in the same way. a roughly quadri- 
 lateral raw surface will still De found to be left. A full- 
 curved needle, threaded with silkworm, or silk, is entered 
 through the skin, at the upper and outer angle of the 
 wound, near the point, T, and made to enter laterally 
 
 Kl(i. 54. — Kmniet's colpo-periiieorrhaphy. 
 Deniul.ilion complete, anil sutures 
 inserted in left triangle. 
 
 Kui. 55.- -Sutures in both lateral tri.ingles 
 tied, leaving quadrilateral denuded 
 surface with sutures inserted. 
 
 deep into the tissues, after which it is curved up under 
 the raw surface to the tongue of the flap, under the tip of 
 which it is passed. The needle is next made to traverse 
 a similar course and emerge through the skin at a 
 point, Tt. on the o])posite side. This is sometimes called 
 the "crown stitcli.'" Half an inch nearer the anus another 
 suture is inserted, and made to travel under the denuded 
 
DISEASES OF THE VAGINA. 171 
 
 surfnco lower down, after which n third nnd fourth, if 
 necessary, are placed in the same order. Tlu' tirst suture 
 is then drawn up and tied, the effect of which is to bring, 
 T, T 1, R, together and form a new commissure by 
 reuniting the upper angles of the original lacerated sur- 
 faces, and interposing between them the crest of the 
 rectocele. The remaining sutures are tied in order, and, 
 if necessary, a few coaptation sutures inserted. 
 
 Emmet's operation for complete laceration is somewhat 
 similar to the method described as Hegar's, and thus a 
 separate description is scarcely recpiired. 
 
 CHAPTER XVI. 
 
 DISEASES OF THE VAGINA. 
 MALFORMATIONS OF THE HYMEN. 
 
 The hymen is a small crescentic membrane which 
 separates the vulvar cleft from the vaginal canal, and may 
 be considered as the portal to the vagina. There are 
 many conformations of the hymeneal membrane all of 
 which may be perfectly normal and physiological (Fig. 8). 
 
 Absence of the hymen. The hymen may be entirely 
 wanting, or only a trace of it may be present, even though 
 the genital organs are perfectly normal, but such a con- 
 dition is exceedingly rare. 
 
 Atresia hymenalis, or imperforate hymen is a 
 malformation in which the hymen forms an imperforate 
 diaphragm. Tliis condition prevents mucous, cast-off 
 epithelial cells and menstrual blood from passing away by 
 the natural channel, and permits of its accumulation above 
 it. In childhood no bad effects will be notice^', except in 
 rare instances arising from accumuhition of mucous. After 
 puberty, the constant repetition of the nu-nstrual period 
 causes an .iccumulatiou of blood in the vagina {luvmnto- 
 colpos), which, by reason of absorption of the serum, 
 
172 
 
 MEDICAL AND SURGICAL (JYN.ECOLOGY. 
 
 sliriuknge of the corpuscles, niul ndmixture of the mucous, 
 bc'coincK converted into a thick, dark browu, tarry mass. 
 Tlie j^'irl pcwsi'ssed of sucli an abnormality has the 
 symptoms of nu^nstruation evi^ry montii, but no blood is 
 scon. The increase of menstrual blood cnust^s pnin, which 
 becomes aggravated each month, and with it occurs the 
 formation of a tumor gradually growing in size from 
 below, upward. If the symptoms of menstruation have 
 persisted for several months, probably enough blood will 
 have accumulated to distend fully the vagina, and to 
 
 cause a bulging of the imperforate 
 hymen. The cervix may next 
 become dilated and distended, the 
 two forming one globular mass, on 
 the top of which may be felt the 
 undilated body of the uterus. The 
 body of the uterus itself may take 
 part in the dilatation {luvnudo- 
 mctra), so that on making a 
 bimanual examination there will 
 be found, lying between the vulva 
 and the hypogastric region, a 
 globular, tense, very slightly fluc- 
 tuating body, corresponding in 
 outline to the distended uterus, a wave of fluctuation 
 being transmitted from the fundus uteri to the i^rotruding 
 surface at the vaginal orifice. The Fallopian tubes may, 
 in their turn, form large tumors, filled with blood 
 {li(T'ni(if<>s(i1j)iii,r), the blood contained in them being not 
 always pressed out from the uterus, but coming sometimes 
 from the mucous membrane of the tubes themselves. 
 
 A (litujnosis can very easily be made, when the 
 history, symptoms and subjective signs are taken into 
 consideration. The tumor formed may nearly fill the 
 pelvic cavity and, by pressure, produce vesical and ri'ctal 
 symi)toms. It may form n tumor in the perineal region. 
 
 KlG. 56. 
 
 -Atresia of the vaginal 
 outlet. 
 
DISEASES OF THE VAGINA. 17)5 
 
 ns Inrgo ns n fcutnl hoad, which finttons out the frenulum, 
 and is continuous witli the skin on tlie distended periucnini 
 nnd Inbin ot the vulvn, in front of which will be found tiie 
 meatus. The dangers arising from such a condition are 
 self evident. Spontaneous rupture through the hymen is 
 very rare, hence, if left alone, it may lead to rupture of 
 the vagina, uterus, or tubes, and even operative inter- 
 ference is not without its dangers. 
 
 Trcdtmcni. When tlu^ tumor is small and confined to 
 the vagina, a crucial incision, or one made by cutting 
 along the insertion of the liymen. is to be made, the cavity 
 irrigated with a warm alkaline solution, such as soda 
 bicarbonate, or lic^uor potassje, and subseciuently with a 
 1 to 2(XX) sublimate solution. To prevcait septic absorp- 
 tion, the cut margins may be touched over with the 
 thermo-cautery, and some strips of iodoform gauze intro- 
 duced to allow for free drainage. When the accumulated 
 mass occupies the uterus, the dangc^rs arising are those of 
 rupture of the tubes and sepsis. To avoid the former, 
 the utmf)st delicacy in manipulation must be observed, 
 and no attempt at rapid evacuation made by pressure on 
 the tumor or otherwise. To avoid the latter a large opening 
 should be matle and the accumulated fluid carefully 
 washed away, the cavity irrigated and free drainage 
 established. If luematosalpinx can be made out before 
 operation, it is best to remove the distended tubciS first, 
 together with the ovaries. The subsecpient treatment 
 will consist in irrigation with antiseptic solutions and in 
 maintaining free drainage until involution has been well 
 established. 
 
 MALFORMATIONS OF THE VAGINA. 
 
 Atresia and Stenosis. The term (itva^id signifies an 
 imperforate condition, and in its strict import is limited 
 to complete closure of nil aperture or canal. Any 
 obliteration or occlusion so extreme as to remove the case 
 from the class of strictures, and yet is not complete, is 
 
174 
 
 MEDICAL AND SURGICAL OYN/EC!()LOOY. 
 
 stylod stenosis. Somo authoritioa uso tlu> term iitrcaia to 
 si^tiity both conditions, marking the divisions by the 
 terms complete and incomptete. 
 
 The vagina, in fojtal lift?, is created from the approxi- 
 mation and amalgamation of the MuUerian ducts ujion 
 the median line, and to arrest of developmcmt of these 
 joarts a great variety of congenital malformations are 
 attributable. There may bo no trace of the vaginal caiml, 
 the ducts of Muller seeming to have failed entirely to 
 
 develop; there may be a distinct 
 fibrous cord marking the site which 
 it should have occupied, somo slight 
 devoloijment appearing to hav(^ oc- 
 curred; development may exist for 
 some distance up the canal, failure 
 having taken place above; or one 
 duct may have developed in part 
 above and another below, giving two 
 cul-de-sacs, separated from each other 
 by impervious tissue. Not rarely 
 the whole canal is ill developed, and 
 the hymen guarding its outlet a 
 closed unyielding membrane — a con- 
 dition often combined with an infantile uterus. The 
 vagina may be divided by a more or less complete 
 longitudinal partition into two halves, eacli of which 
 corresponds to one Mullerian duct — a condition often 
 combined with double uterus. Double vagina may be 
 combined witli atresia on one or both sides, and if one 
 side is pervious, the condition may be overlooked for a 
 long time. While congenital defective development is 
 one of the frecpiont causes of atresia and stenosis, it may 
 occur as a result of injury from mechani(!al, chemical, or 
 pathological agencies. A vagina once fully developed 
 may close entirely from adhesions of its walls, or its 
 calibre may be diminished by absolute removal of its 
 
 Fit;. 57- — Extern.al appearance 
 of (loulile vagina. «, /', 
 v.^gillaI orifices. 
 
DISEASES OF THE VAGINA. 175 
 
 coinpoiuMit Htru(!tuniH in consoquonco of Hloughin^ pro- 
 duced by impaired vitality, by prolonged or difficult labor, 
 by chemical agencies locally applied, or by syphilitic or 
 other extensive ulceration. 
 
 Hi/nii>f()nii<. T\w condition will demonstrate its ex- 
 istence oidy by incapacitating tlu^ vaginal canal for the 
 p(vrff)rmance of its functions. Should it occur in ont> too 
 old, or too young, to rec^uire such funtitions from the 
 vagina, it may attract no notice. Amenorrluua alone, or 
 combined with those symptoms of retained menstrual 
 blood already describcnl when spi^aking of imperforate 
 hymen, or inability to perform the act of coition, will 
 probably first bring tlu> sufferer under notice. On making 
 a physical examination, the entrance of the finger into, or 
 up the vagina, will b(^ found difficult or impossible. In- 
 vestigation will prove that it is not due to vaginismus, or 
 udhesion of the labia. The introdut^tion of a sound into 
 the bladder, and the finger into the rectum, may discover 
 the canal running up as a fibrous cord, or no tracer of it 
 whatever may be found. DoubU> vagina can generally be 
 very readily made out, but when there is atresia on one 
 side the diagnosis may not be so easy. In this there will 
 be a menstrual discharge from the open side and retention 
 in the other half, ff)rming a luiMuatocolpos or hiumatometra. 
 From UK're occlusion of tlu^ vagina there is no imnu'diate 
 or direct derangemc^nt, but in those cases where ther(> is 
 retention and accumulation of menstrual blooil in the 
 portion of the canal above the stricture, or in the uterus, 
 the danger assumes the same proportions, or even greater 
 than in imperfon.te hymen. 
 
 Trcatincnt. The possibility of removing tlu^ abnormal 
 state will depend upon the extent and completeness of the 
 obliteration, or upon tlu^ destruction of tissue. General 
 uarrowni^ss, due to arrest of development, may be success- 
 fully treated by the introduction of graduated dilators, 
 anil the treatment kept up until it has reached the normal 
 
176 MEDICAL AND SURGICAL GYNMJOLOGY. 
 
 size. Whou ntrosin occurs from tho pr(>Hoiic(> of a mem- 
 brnue nbovo tlir hymon {scj)(i(iu rctro-liijinciKflc). it is to 
 bo trimtod on the snmo principles ns for ntresia of the 
 hymeii. 
 
 If, in complete congenital closure or absence of tho 
 vagina, the uterus be found to be absent also, no attempt 
 should be made to make a vagina, as it is hardly justifiable 
 to expose the patient to the dangers of operation mi^t^ly in 
 the hop(^ of forming an organ of copulation, besides the 
 artificially formed vagina is apt to close again. The 
 situation is entirely different when there is a uterus, with 
 attempts at menstruation or retention of the menstrual 
 flow. Under such circumstances operative interference is 
 imperative. The patient is placed in the dorsal position 
 and the legs elevated by Clover's crutch. A transverse 
 incision is made midway between the urethra and anus. 
 The operator works his way slowly and very carefully up 
 between the bladder and rectum, insinuating his way with 
 fingers and closed blunt scissors, keepiiig at the same time 
 a metal catheter in the bladder. The left forefinger in 
 the rectum will locate the position of the cervix and in- 
 dicate tho direction in which the operator must work to 
 reach it. After reaching tho cul-de-sac and the cervix 
 exposed, tho opening is stretched, accumulations removed 
 if present, observing tho same care as heretofore expressed, 
 and the parts carefully irrigated. A few strips of iodo- 
 form gauze may be introduced into the fornices, after 
 which a hollow glass tube covered with gauze, and jiropor- 
 tionate in size to the new formed vagina, is inserted and 
 held in position by a "T" bandage. Tho tube should be 
 worn for a month at least, during which it should be taken 
 out daily and the parts irrigated. Subsequently tho plug 
 should be worn for an hour each day during a whole year. 
 If absence of tho vagina is combined with absence of tho 
 uterus, but active ovaries present, they should be extir- 
 pated. 
 
DISEASES OF THE VAGINA. 177 
 
 In floublo vngiiin, If tlio w^ptuni inti'rfi^rcs witli coition, 
 it may bo Hi)lit U^nf^thwise and the marj^ins touclu'd with 
 tlio tliornio-cautory. DoubU^ vagina, with unihitcral or 
 bilateral atresia and retention of the inenHtrual fluid, may 
 bo mistaki^n for luematocele, or a uterine myoma, unless 
 the history of the case is carefully taken into consideration. 
 Unilateral atresia may b(^ treated by introducin?^ a 
 sinnnilum into the open half, and openinj^ into i\\" otlur 
 by means of scissors or thermo-cautery. In double atresia 
 one side may be opened first, as in atresia of the single 
 vagina, and afterwards the septum incised. 
 
 Faulty communications. As a result of arn-st of 
 development other conditions are sonii'times met with. 
 There may be complete atresia, or absence of any opening 
 on the cutaneous surface leading into the intestinal or 
 uro-genital canal, while under the skin is found a common 
 cloaca, into which open the bladder, vagina and rectum. 
 In other cases the vagina and urethra apparently open 
 into the rectum, being cases of persistent cloaca. The 
 partition between the rectum and the uro-geiutal sinus 
 may have been formed, but tlu^ urethra seems to opt'n into 
 the vagiim -a condition die to persistent uro-genital sinus. 
 
 VAGINITIS. 
 
 Vaginitis is the word commonly used to (h^signate 
 inflammation of the vagina, but some autliors, however, 
 have substituted the word colpitis or cli/trifis. 
 
 Under this term is comprised so many different con- 
 ditions that it is necessary to admit certain divisions 
 and subdivisions of the subject. Thus the intensity of 
 the symptoms and the length of timi^ which the disease 
 lasts, classifies it as (irufc or chronic. It is called prinnrrif 
 when it appears first in the vagina; accotuUtrji when the 
 inflammation invades the organ from another part. 
 
 Taking the chief features of the disease into consider- 
 ation, vagiiiitia may be classified as simple, yonorrlujcal, 
 
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 Sciences 
 
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 (716) 872-4503 
 
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178 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 and (jranular, and to this clnssificntion may be added the 
 (iplithous. cfjsfic, adhcsivo, vesicular, and onphysonah.ns, 
 as forming less important varieties. 
 
 ^tiolofjy. Any intluence which injures the vaginal 
 epithelium, such as long continued friction from foreign 
 bodies, or chemically irritating secretions or injecta, 
 diminishes the resisting power of the vfiginal mucous 
 membrane. If accompanied by lack of drainage, and t \ 
 consequent accumulation of secretions, bacteria multipl;y, 
 infection follows, and vaginitis results. Among the 
 prcdisjiosinji causes may be mentioned anaemia; chlorosis; 
 constipation; any of those causes which tend to produce 
 unhealthy conditions of the skin; pregnancy; abdominal 
 tumors, or other conditions which tend to produce pelvic 
 congestion. Masturbation; pin worms; pessaries; tam- 
 pons; chemical irritants; retained secretions; pathological 
 secretions from the uterus, urethra, or vulva, or infection 
 introduced from without, such as gonorrhoeal pus, may be 
 enumerated among the exciting causes. The exanthemata 
 are held accountable for a small share of the cases. 
 
 PathoUnjij. In the acute stage of simple vaginitis, 
 hyperffimia and enlargement of the papilliB take place, 
 with small celled infiltration of the epithelial structure. 
 The epithelium on the summits of the papillfc is shed, but 
 between them it is thickened. The discharge in .some 
 cases is thin and slightly acid; in others it is alkaline and 
 thick; in others purulent. In the chronic form the 
 deeper layers of the membrane become infiltrated, with 
 loss of epithelium in some places, giving rise to ulceration. 
 When caused by chemical irritants, such as strong solu- 
 tions of iodine, a sort of vesication may oc^ur, with 
 exfoliation of large layers of epithelial tissue having the 
 appearance of a false membraiu>. In the gonorrhoml 
 variety the changes are similar to those mentioi'^d, but 
 more pronounced. The papilhe are larger and more 
 vascular, the vestibule and inner surfaces of the labia 
 
DISEASES OF THE VAGINA. 179 
 
 participnto in those clmugos, while the discharge from tlie 
 first is muco-puruhMit. Later the discharge becomes 
 thinner and more distinctly purulent, and may give rise 
 to infection of the urethra, vulva, and vulvo-vaginal 
 glands. 
 
 Graanlar vaginilis differs chiefly by the more jjro- 
 nounced enlargement of the papilhe and by more extensive 
 exfoliation of the epithelium covering tliem, causing the 
 surface to resemble a mass of granulations. 
 
 Adhesive V(i<)iiiitis is a disease of childnni and old 
 people. In them the prtpillffi are smaller and the epithelial 
 layer thinner. The inflammation is usually found more 
 in patches, the secretion scanty, the surface smoother, and 
 often ecchymotic ia spots. The opposed surfaces tend to 
 agglutinate, and by this means the lumen of the fornices, 
 or even of the whole vagina may become obliterated. 
 
 Cystic or follicfdnr raf/iuitis consists of an inflamma- 
 tion in the follicles occasionally situated about the vaginal 
 fornices, causing the retention of their contents and the 
 formation of small cysts. 
 
 Aplitliovs viujinHis arises from a development of the 
 oidiurn albicans on the congested or more or less eroded 
 vaginal surfaces, giving rise to whitish patches. 
 
 Vesicular raijinitis gives rise to round vesicles situattnl 
 on inflamed areas, which, after bursting, leave sharply 
 defined raw surfaces about the size of split peas. 
 
 Emphjisemaions va(jinitis is an inflammation of the 
 vagina characterized by the development of fluid and gas 
 in the small spaces and canals of the connective tissue and 
 lymphatics at the upper end of the vagina. They project 
 like little bladders on a raised hyperannic base, produce 
 a crackling sensation when felt, and collapse when punc- 
 tured. Pregnancy favors the development of this form. 
 
 Sympfonis. Acute vaginitis is indicated first by a dull 
 pain in the pelvic region, and a sensation of heat and ful- 
 ness in the vagina, accompanied by a slight rise of tern- 
 
180 MEDICAL AND SURGICAL ftYN^COLOGY. 
 
 perature and a feeling of malaise. There is a discharge 
 which is at first scanty, but rapidly increases in amount, 
 and often possesses a disagreeable odor. Micturition and 
 defecation become painful, conditions which may soon be 
 followed by severe urethral and vesical symptoms, such as 
 frequent urination accompanied by burning pain and 
 vesical tenesmus. Urethral and vesical symptoms indicate 
 with fair certainty thnt the causative agency is one of 
 gonorrhoea, particularly if accompanied by pain or tender- 
 ness in the inguinal region. Digital examination shows 
 the vaginal orifice to be sensitive, the canal hot and 
 swollen, and at a later period roughened. If the urethra 
 be involved, it will be found thickened and tender, and 
 pressure along its course may cause a drop of pus to exude 
 from the meatus. Pus from this quarter is said to be con- 
 clusive evidence of gonorrhoea also, as gonococci thrive 
 best upon its mucous membrane. If the bladder becomes 
 infected, pressure on the vaginal wall will reveal the fact 
 by the marked increase in the pain produced. Inspection 
 will show the vulva acutely inflamed and covered with a 
 muco-purulent or purulent discharge. 
 
 The symptoms of chronic vaginitis are similar, but 
 less pronounced. In some cases symptoms of importance 
 are absent altogether, and nothing, except a leucorrlux3al 
 discharge, calls the patient's attention to her condition. 
 It may follow the acute stage, but more often is, from the 
 first, a subacute or chronic process, such, ivT instance, as 
 that form which develops in consequence of discharges 
 from the direction of the uterus, or as the result of senile 
 changes. The more acrid and abundant the discharges 
 become, the more likely will they produce vulvitis and 
 pruritus. Touch and sight reveal the rouglunied surfaces 
 and, if of the gonorrluwal form, vegetations are not 
 uncommon. With the symptoms described, a vaginitis 
 should not be confounded with any other lesion, but it is 
 not always easy to distinguish one form of vaginitis from 
 
DISEASES OP THE VAGINA. 181 
 
 auotluT. The presence of the gonococcuH may establish 
 the presence of one form, but its absence is not adecpiate 
 proof of the absence of such infection. Corroborative 
 evidence in its favor is found, however, in other directions, 
 the prominent points of which have already been related 
 when speakinj^ of vulvitis. 
 
 Treafnicnf. Simple acute vaginitis is readily controlled 
 and cured by keeping the patient at rest, by freeing the 
 bowels with mild cathartics, and by the copious use of 
 douches, consisting of a strong aqueous solution of boric 
 acid, borax, or of bicarbonate of soda, at a temperature 
 of 105° to 110° F., every four hours, the vagina being 
 stretched by means of a wire speculum to permit of its 
 application to every part. If the tenderness is so groat as 
 to exclude the use of such an instrument, a soft cutheter 
 may be used, aided by hot alkaline fomentations applied 
 to the external genitals. If there is a suspicion that it is 
 of a gonorrhaml type, or in cases in which the simple form 
 does not readily yield, the fluid used for douching should 
 contain instead of alkalies, bichloride of mercury 1 to 
 5(XX). If the disease shows a tendency to become chronic, 
 more energetic local measures become necessary. Through 
 a Sims' speculum, the vaginal walls are to be carefully 
 cleansed with green soap and warm water, then wiped 
 over thoroughly with a solution ol bichloride 1 to 1000, 
 followed by another washing of warm water. After 
 cari'fully drying with absorbent cotton, the vagina is to 
 be lightly packed with plain or borated absorbent cotton, 
 or the surfaces kept apart by tht introduction of three or 
 four thicknesses of gauze. This treatment should be 
 repeated daily, until the disease is conquered. In the 
 chronic form, the same careful cleansing is to be carried 
 out but, instead of the bichloride, the entire surface is to 
 be painted with a Hve per cent, solution of nitrate of 
 silver, after which gauze is to be inserted as before and 
 allowed to remain for twenty four hours. This treatment 
 
182 MEDICAL AND SURGICAL, GYN/ECOLOGY. 
 
 should bo given every three or four days, and in the 
 intervals warm borax douches niglit and morning. Treat- 
 ment by dry powder, such as ecpial parts of bismuth and 
 chalk, or tannin and chalk, and kept in places by a cotton 
 tampon, often proves serviceable when there is a tendency 
 for the discharge to linger. The powder and tampon 
 should be removed every day, the old powder being 
 douched out just before the treatment is repented. Sup- 
 positories of tannni, oxide of zinc, or acetate of lead may 
 be similarly used, with equally good results. In the 
 senile and vesicular forms, mild antiseptic douches are 
 indicated, supplemented by strips of lint smeared with a 
 two per cent, carbolized oxide of zinc ointment and 
 introduced within the vagina. 
 
 Neoplasms. Cysts are rather frequently found in the 
 vagina of adults or, as congenital formations, in new born 
 children. They are usually single, globular or oblong, and 
 for the most part sessile, but may become pedunculated. 
 They vary in size from that of a pea to a goose egg, 
 but may, exceptionally, reach the size of a foetal head at 
 full term. The contents may bo serous, yellowish, 
 purulent, or thick and chocolate colored. Those cysts 
 may have different origins. They may be formed by con- 
 densation of the peri-vaginal connective tissue around an 
 extravasation of blood, or they may be simple retention 
 cysts. Remains of an ununited du3t of MuUer or of the 
 canals of Grartner may give rise to them. If small they 
 may not give rise to any symptoms, but are discovered 
 accidentally during delivery, or an examination. They 
 may be diagnosed from a cystocole or rectocelo by the 
 introduction of a catheter into the bladder, or the tinger 
 into the rectum. 
 
 The treatment consists in making an incision over the 
 tumor and enucleating the entire cyst wall, if possible. 
 When unable to do this, removal of as much of the cyst 
 
DISEASES OF THE VAGINA. 183 
 
 wall as possible is to bo accomplisluMl and the remainder 
 caiiteri7A>(l and packed with iodoform j^aiize. 
 
 Fi'hronid ((ltd Jiln'(,mi/())ii<i arv rare. Their most com- 
 mon Hcni is in the upper jiart of the anterior vaginal wall. 
 Orifjcinally they are globular, sessile tumors, but when 
 their weight increases they have a tendency to become 
 pedunculated, and may even protrude through the vulva. 
 When they are small they are easily diagnosed by their 
 elastic hardness, but when large they may be mistaken for 
 a uterine pedunculated fibroid. If, however, the os can 
 be reached, it will be undilated and no pedicle will bo 
 found passing through it. 
 
 Treahmmt. If sessile, it may be removed by making 
 an incision over its longest diameter and, after enucleating 
 it, the cavity closed by rows of superficial raid deep catgut 
 sutures. If pedunculated, the pedicle may be secured by 
 ligature and the mass cut away. 
 
 Mhcoks polypi are very rare. In shape and structure 
 they are similar to the mucous or glandular jjolypi found 
 in the cervical canal. 
 
 Prinud'i/ cfcrhwdKi is also fl rare disease. As a rule 
 it is secondary, either propagated by continuity from 
 neighboring organs, or appearing as metastatic deposits 
 from carcinoma in remote parts. As a primary affection 
 it occurs in the form of epithelioma and submucous 
 carcinoma. Epithelioma usually begins as a circum- 
 scribed projecting nodule on the posterior wall of the 
 vagina, which soon breaks down on the surface and 
 assumes the form of a raised, ulcerating, cauliflower-like 
 mass, with everted edges. The submucous or diffuse 
 variety commences as a flat area of infiltration, under the 
 normal vaginal membrane, which spreads along and around 
 the vagina, until the latter feels like a narrow opening 
 through a mass of hard unyielding tissue. Ulceration 
 and excavation sooner or later take place, with corres- 
 ponding softening of the parts. The sijmpfums are at 
 
184 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 first confined to a thin irritating dischargo, wliich bi^forc^ 
 loufr becomos ott'onsivc, bloody at times, and containinj^ 
 Homo tissue debris. Pain, radiating from the vagina, is 
 soon experienced, and later t!io symptoms are those which 
 characterize infection of the neighboring organs. The 
 treatment consists in extirpating the dis(uised tissues, 
 whenever possible, and thorougldy cauterizing the wound. 
 When it is no longer possible to remove ail the tissue, the 
 surface may be curetted, and a solution of ''orric chloride 
 applied once a week, if it is tolerated that ot*^^en. Astrin- 
 gent and antiseptic douches will help to diminish hemor- 
 rhage, destroy the odor, and prevent septic absorption. 
 
 CHAPTEB XVII. 
 
 GENITAL FISTULA. 
 
 Genital fistulae are abnormal avenues for fecal or 
 urinary discharge, by moans of which some portion of the 
 intestine or urinary tract communicates with the genital 
 tract. 
 
 Fecal fistulse are formed by a communication bet ween 
 the rectum or the small intestine, and the uterus, vagina, 
 or bladder. 
 
 Urinary fistulae are formed by the bladder discharging 
 into tho uterus or vagina; by an opening from the urethra 
 into the vagina; or by a ureter emptying into the uterus 
 oi vagina. They have been designated as vesico-vaginal, 
 urethra - vmjinal, vesica - uterine, vesica - utera - vaginal, 
 utera-vag inal, nretero-uterine. and uretera-vesica-vaijinal. 
 
 Vesico-vaginal fistula is a communication between 
 the bladder and vagina, and is by far the most common 
 form. These tistuhe may originate from protracted labors, 
 in which the bladder has boon compressed between the 
 head of the child and the symphysis pubis sufficiently 
 
GENITAL FISTULA. 185 
 
 long to produco n locnlizod nocrosis, niul tbo necrotic 
 tissue thus formed, coming nwny after a period of a few 
 days, establishes the fistulous tract. They may also arise 
 from direct injury to the tissues from the use of forceps, 
 or from injury sustained during surgical oj)erations in the 
 neighborhood of the bladder, particularly hysterectomy. 
 Other agencies may create them, such as pessaries, stono 
 in the bladder, or the presence of other foreign bodies. 
 The vaginal walls may be perforated by cancer, or by 
 syphilitic or other ulcers, or by the formation of an abscess 
 in the parietal tissues. Lastly, certain diseases, producing 
 deficiency of nutrition, may cause localized sloughing of 
 the vaginal walls. 
 
 Sijmptoms. The chief symptom is indicai3d by a more 
 or less constant dribbling of urine from the vagina, accom- 
 panied by a disagreeable ammoniacal odor. By the 
 passage of this irritating excrementitious material through 
 a canal and over tissues not intended by nature to tolerate 
 it, inflammatory action, pruritus, eruptions and excessive 
 irritability are produced, and the vagina sometimes becomes 
 covered with urinary concretions, and the vulva and thighs 
 red and excoriated. If the fistulous orifice be a large one, 
 even a superficial examination by touch will reveal the 
 nature and extent of the lesion, but the opening may be 
 so small, or so hidden behind the projecting cicatrix, that 
 it cannot be discovered. For their detection a Sims' 
 speculum should be employed, with the patient in the 
 genu-pectoral position, injecting at the same time, if 
 necessary, an infusion of India ink, cochineal, madder, 
 indigo, or plain milk. 
 
 Treatment. A fresh fistula, even if of considerable 
 size, may be much diminished, and sometimes closed 
 altogether, by the use of warm vaginal douches, and by the 
 internal administration of drugs to render the urine 
 normal, such as salol, or benzoic or phosphoric acid, or 
 benzoato of ammonia. When a fistula has been discovered 
 
1H(> MKDUIAL AND STHdlCAL (iYNECOLOOY. 
 
 soon after parturition, it hIiouKi bi- treated by such 
 nil thods, as it is too early to resort to suture. The once 
 favorite inetliod of treating all varieties of these Hstuhe by 
 cauterization has now, very deservedly, faHeii into disuse 
 under the inHuenee of improved surj^ieal methods. 
 
 Closure by siitinw <(f the Hcaf of tlw Jhfiiln. This is 
 the most reliable and satisfactory of all methods. The 
 best time for operating is eight or nine weeks after con- 
 finement, at a period when the patient has regained her 
 constitutional vigor, for in no operation in surgery is this 
 more vigorously demanded. The pvcporotorii tt'catnicnt 
 consists in the use of the same nu'asures as have just been 
 mentioned, namely, warm vaginal douches, the adminis- 
 tration of drugs to render the urine unirritating, and the 
 careful removal of incrustations. If cicatricial bands 
 exist they are from time to time to be cut with a knife or 
 scissors, and the vagina stretched by tht> introduction of a 
 Bo7AHnan's dilator. 
 
 trims' opcrotion. This operation may be divided into 
 three parts; paring the edges of the fistula; passing the 
 sutures; and apjjroxi mating and coaptating the denuded 
 surfaces. The patient is placed in Sims' position and a 
 large broad-bladed speculum introduced into the vagina. 
 The (.'dges of the fistula are caught up witli a tenaculum 
 and, with scissors, the edges pared all round, to the extent 
 of producing a raw edge one-third of an inch wide, and 
 bevelled from the vesical mucous membrane outward to 
 the vagina, care being taken not to imijlicate the former 
 in the incision. Two sorts of sutures should be used in 
 approximating the denuded margins, silkworm for the 
 deep, and fine silk for the superficial stitches. Beginning 
 at the most remote portion, a slightly curved needle is 
 entered half an inch from the edge of the incision and 
 brought out on the denuded surface, just under, but not 
 including the edge of the vesical mucous membrane. 
 After drawing the suture partly through, the needle is 
 
GENITAL, nSTUL.E. 
 
 LS7 
 
 iiitroducu^d jigaiii into tlu* raw Hurfnn^ ()i)i)()Hiti'. jiiKt uudor 
 the vosic^nl ituk^ouh iiuMnbraiic, mid n\ndv to ciiuTj^c lialf 
 an inch from the edge of the wound. The otlier .sutun^s, 
 tivo or six to the inch, are iiiiroduced similiarly, and one 
 at, or just beyond each angle of the wound. The sutures 
 are then brought together and tied .snugly, approximating 
 the tissues without strangulation, after wliich the margins 
 may be mor(> carefully coaptated by sup(^rficial sutures. 
 Tho ends of the sutures having been cut ott*, a loose 
 iodoform gauze pack is placed in the vagina. A self- 
 retaining catheter, preferably of soft rubber, may bo 
 introduced, after carefully washing out the bladder. Many 
 surgeons prefer to trust to frequent catheterization for a 
 
 Fig. 58 — Operation for vesico vagiii.il fistula, denuclalion complete, and sutures in place. 
 
 few days, believing that the constant presence of the 
 catheter keeps up continued vesical tenesmus and lessens 
 the chances for immediate union. If the vaginal pack 
 bc^comos wet or soiled, it should be removed, otherwise it 
 may be left in place for two days, when it should be taken 
 away, antl the vagina allowed to remain empty. 
 
 When the operation was first perfected by Sinii, 
 silver wire, introduced by silk carriers, was used ex- 
 
188 MEDICAL AND SURGICAL GYN.ECOLOGY. 
 
 cluHivoly, but it in found tlint Hilkworm servoH oqunlly 
 an W(^ll. 
 
 Tivo ofluT <>f)cr<itions Jiro gouorully doHcribcHl for tho 
 closure of vesico-vagiunl tistuhe, namely, Simon's and 
 Bozemau's, but as they dittVr mostly in the matter of 
 technique, and in tho method of procedure, it is not 
 (!onsi(lere(l necessary to describe the various stejjs. 
 
 There is a y/ff;;-.s7>///////// (>j)('f((fi<)n, known as Blazius' 
 method, and recently rem wed by Lawson Tait and others. 
 No tissue is cut away, but an incision is made parallel to 
 tho vaginal and vesical mucous membrane, on tho white 
 lino of the cicatrix, to the depth of three-eighths of an 
 inch. The vesical and vaginal flaps thus formed are 
 separated and, in the cleft formed, a vircular suture is 
 introduced, which, when drawn up, approximates the raw 
 surfaces all around. 
 
 Urethro-vaginal. In this variety the wall of the 
 .septum being very thin, the denudation must be extended 
 over the nearest part of the vagina and the edges brought 
 together from side to side over r. metal catheter. If the 
 tension is great, it may be relieved by n. cing an incision 
 on each side parallel to the line of union. 
 
 Vesico-uterine. From its anatomical relations, fistulous 
 communication can only take place between the bladder 
 and uterus at the cervix, except under rather rare circum- 
 stances. These fistulte are produced in the same manner 
 as vesico-vaginal fistuloe, and form small round holes 
 opening through the anterior lij, of the cervix. It, too, 
 may be diagnosed by injecting milk or colored fluid into 
 the bladder. Sometimes a probe can be brought from the 
 bladder, through the fistula, into the cervical canal. 
 
 Trenhncnt. This kind of fistula has an unusual 
 tendency to spontaneous healing, and efforts of nature in 
 this direction may be aided by cauterization. If that 
 does not succeed it may be closed by operative i^rocedure. 
 After having split the cervix in the median line, so as to 
 
GENITAL FISTULiE. 189 
 
 ronch the fistulous trnct, and denuding its surfaces, 
 sutures nro introduced through the uterine and vesical 
 walls, after wliich tlu^ incision in the cervix is closed the 
 same as in tracludorrhaphy. 
 
 Vesico-utero-vaginal. In this variety the fistulous 
 tract i)asses from the bladder through the anterior lip of 
 the cervix and ends in the vagina. They are subdivided 
 into superficial and deep, according to whether tlu^re is 
 partial or comi^lete sloughing of the anterior cervical lip. 
 In the superficial form, good results may be obtained by 
 simple denudation and suture, but the deep are rarely 
 amenable to treatment by this metnod, and it is generally 
 necessary to bring the posterior lip of the cervix in 
 apposition with the vaginal edge of the fistula, and stitch 
 the two together. The os uteri therefoi-^ will open directly 
 into the bladder. This operation has been termed vesico- 
 hijiitcro-alcisis. 
 
 Uretero-vaginal. A uretero-vaginal fistula is situated 
 on the anterior wall of the vagina, a little below and 
 outside of the vaginal portion of the uterus, and is formed 
 between the ureter and vagina. The causes are, difficult 
 parturition, perforation of a pelvic abscess, prolonged use 
 of pessaries, and vaginal and abdominal hysterectomy. 
 
 Difu/nosis. By placing the patient in the dorsal 
 position and exposing the vaginal vault, the fistulous 
 opening may, with a little patience, be found, though it 
 be only the size of a pinhead, or smaller. With a probe 
 or ureteral cathoter, it is usually possible to enter the 
 ureter for some distance and see the urine coming out 
 drop by drop. A catheter or sound passed into the 
 bladder will reveal the absence of the probe there. Milk 
 introduced through the urethra will not escape through 
 the fistula. Cystoscopic examination will positively clear 
 up the diagnosis. With the ureteral catheters introduced 
 no urine will come from the catheter on the affected side, 
 while on the opposite side it will issue drop by drop. 
 
Ill 
 
 l^R) MEDIOAL AND SURGICAL GYNitCOLOGY. 
 
 Trrdtmrnt. All uretoro-vnginni fistulre should bo 
 operated upon ns soon as circumstnucos will permit, on 
 account of the great liability of the kidney to become 
 infected. Three operations are available, closure of the 
 fistula, implantation of the ureter into the bladder, and 
 nephrectomy. 
 
 1. An elliptic incision is made around the fistula, the 
 ureter exposed, and a sound passed into its orifice. After 
 freeing the ureter for about one third of an inch, an 
 opening is made into the bladder, just above the end of 
 the ureter, and, after removing the sound, the free end of 
 the ureter is turned into this opening and ludd there by 
 two or three fine sutures passing through the vesical and 
 ureteral walls, but sufficiently superficial as not to 
 encroach upon the lumen of the ureter. The vaginal 
 incision is then closed carefully. 
 
 2. If a vesico- vaginal fistula does not already exist, one 
 is made by the excision of an oval flap around the ureteral 
 oijening. The end of a very fine gum elastic catheter is 
 then passed into the renal end of the ureter, and the other 
 end into the urethra by way of the fistulous opening in 
 the bladder. The geuu-pectoral position is now assumed 
 and the edges of the fistula denuded. A series of fine 
 sutures are passed through the flaps, at right angles to the 
 ureter, and tied. The catheter must remain in position 
 for at least eight days, and the bladder kept empty for a 
 portion of that time by a self retaining catheter or by 
 frequent catheterization. 
 
 3. Implantation of the ureter in the bladder. (Uretero- 
 cystostomy). After opeidng the abdomen, the ureter is 
 dissected out low down, and an opening made in the 
 posterior wall of the bladder by cuttmg down on closed 
 forceps introduced through the ureiiira. A flexible 
 catheter is introduced into the ureter and pulled out 
 through thxC urethra. The ureter is then fastened to the 
 wall of the bladder by fine sutures, after which the flaps 
 
GENITAL FISTULA, 
 
 191 
 
 of peritoneum are mnde to cover over aud close off the 
 point of entrance, fine silk sutures being also introduced 
 for that purpose. If there is difficulty in selecting the 
 proper point for oijoning into the bladder, it may be 
 partially filled with boric acid solution, which is at once 
 to be evacuated after the point has been selected. Finally 
 a self-retaining soft rubber catheter is to be inserted 
 through the urethra by the side of the ureteral catheter, 
 after which the abdominal wound is closed. 
 
 Uretero-uterine fistula. In this variety the urine 
 flows from the oh, as in the vesico-uterine, but the 
 mt^thods adopted to ditt'erentiate between vesico-vaginal 
 and uretero-vaginal and vesico-uterine will be sufficient to 
 make a diagnosis. This form of fistula is exceedingly 
 rare, and if abdominal implantation cannot be performed, 
 relief may be obtained by turning the cervix into the 
 bladder, by artificial closure of the vagina (colpo-cloisis), 
 or by excision of the corresponding kidney (iie])hrectomy). 
 
 Indirect methods for the relief of urinary fistulae 
 have been devised. They consist in the closure of the 
 genital canal, at a point below the site of the fistula, so 
 that the portion of the vagina above becomes a part of the 
 bladder, menstruation, if present, taking place into this 
 viscus. Three varieties have been devised : — Antero- 
 posterior closure of the vulva (episio-cU^isis) ; complete 
 vulvar closure with the formation of an artificial recto- 
 vaginal fistula; and the obliteration of the vaginal canal 
 transversely (colpo-cleisis). The two former have proved 
 so unsatisfactory that tliey have been jiractically aban- 
 doned. 
 
 Colpo-clcisifi. In performing colpo-cleisis care should 
 be taken to preserve as much of the depth of the vagina 
 as possible, and theriifore closure should not be made at a 
 lower point than necessary. A ring of mucous membrane 
 is marked out on the vaginal wall, and with a sound in 
 the bladder, the anterior surface is denuded, and with the 
 
192 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 finger in the rectum, the posterior surface. Sutures are 
 passed by means of two short half-curved stout needles, 
 one at each end, the anterior needle being passed from 
 above downward, under the denuded surface of the vesico- 
 vaginal wall, and the posterior needle similarly, under the 
 denuded surface of the recto-vaginal wall, and, after all 
 are inserted, they are carefully tied. 
 
 FECAL FISTULA. 
 
 |j;| Fecal fistulse are abnormal avenues for the escape of 
 
 the contents of the small or laige intestine, either by the 
 vagina or by the bladder. Implication of the small 
 intestine is comparatively rare, and that of the bladder 
 extremely sp. The fistulous communication may take 
 place between the rectum and vulva, recto-hihuil; between 
 the rectum and the vagina, recto-vagimd; or between the 
 ileum or sigmoid flexure and the vagina, ilco-vaginal, or 
 entero-vaginal. 
 
 The size of the opening varies. It may bo so small as 
 to be found with difficulty, or large enough to admit a 
 fiiger. It may be situated anywhere between the intestine 
 and vagina, but it is most commonly found either immedi- 
 ately above the sphincter ani or at the fornix. The causes 
 of fecal fistulae are in many respects similar io those 
 determining urinary fistulje, but the most common by far 
 is child-birth. The symptoms are plain. The escape 
 of flatus and, when the bowels are loose, of their fecal 
 matter through the vagina, readily indicates the condition, 
 but when the fistula is very small there may be some 
 difiiculty in locating it. Distension of the rectum with 
 water will often bring the opening into sight. 
 
 Treatment. Many small fecal fistula? have a decided 
 tendency to close naturally, and this happy result should 
 be facilitated by scrupulous cleanliness, sitz baths, rectal 
 and vaginal injections, laxatives, and by an occasional 
 light cauterization. 
 
GENITAL FISTULyE. 193 
 
 Rccto-lahial fistula is best treated as a fistula in nno. 
 If the labial opening be near the rectum it may be cut 
 through, the fistulous tract curetted or denuded, and either 
 packed with gauze, leaving it to heal by granulation, or 
 the surfaces brought together with deep sutures, to heal 
 by immediate union. 
 
 Many operations have been devised for the cure of 
 recto-vaginal fistulse: — 
 
 1. Emmefs operation consists in splitting the perineal 
 body up to the fistula, cutting its wall away, and uniting 
 the same as in complete rupture of the perineum. 
 
 2. The fiap-splittiiKj mctJiod described for the cure of 
 vesico-vaginal fistula often gives good results when the 
 opening is small. 
 
 3. Make a broad denudation on the vaginal side and 
 extending from the sound tissue deep down into the 
 fistula. De<ip and superficial sutures are passed from 
 side to side. 
 
 4. Make a vertical incision in the median line, extend- 
 ing half an inch above and below the fistula, and dissect 
 the vaginal from the rectal wall on each side, for a 
 distance of half an inch. Unite the edges of the rectum 
 by a continuous buried catgut suture inserted from the 
 vaginal side, and afterwards the vaginal flaps by silkworm 
 or chromic catgut. 
 
 Ent<'ro-va(/inal fistula', when the opening is lateral, 
 may be closed by denudation and suture like other fecal 
 fistuljB. In the case of raxjinal anus no attempt at closure 
 must be made until it is ascertained that the lower part of 
 the bowel is pervious. 
 
 In ilro-vaginal fisfuhv, and in fistulous openings 
 bv>tween the bladder and intestine, the oidy plan of treat- 
 ment is to open the abdomen, find the fistulous tract, 
 sever the adherent intestine if possible, and, by means of 
 Lembert sutures, close the openings in both viscus. 
 
194 MEDICAL AND SURGICAL GYNiECOLOGY, 
 
 CHAPTER XVIII. 
 
 DISEASES OF THE URETHRA AND BLADDER. 
 
 Malformations of the urethra. Tlio urethra may be 
 entirely absent, due chiefly to arrest in development of 
 the vagina at a point where it should form the main 
 portion of the posterior wall of the urethra. 
 
 The lower and anterior portion of the virethra may 
 be absent (hyi)ospadias). 
 
 Airesia of the urethra is a comparatively common 
 affection. There are two forms mentioned: one is produced 
 by imperfect development of the vaginal process, or of 
 both the clitoral and vaginal segments, the urethra being 
 open up to the bladder and there closed. The second form 
 occurs when the clitoral and vaginal processes are both 
 defective. In such cases there is no trace of a urethra, 
 except an imperfect vaginal wall, which extends obliquely 
 dowiuvaid and closes the bladder. The symptoms which 
 aris* from malformation of the urethra are incontinence 
 of ur* in the one cla.ss of cases, and retention in the 
 other. vV'hen the urethra is deficient in part, and the 
 bladder perforate, urine constantly escapes. Atresia of 
 the urethra and the consequent retention of urine 
 causes hydrops of the bladder, ureters, and kidneys. 
 Distention of these organs occurs in utcro, and such 
 malformed children are usually born dead, or die soon 
 after birth. The evil effects of this malformation is 
 sometimes naturally obviated by the occurrence of another 
 developmental anomaly — fistula of the urachus and escape 
 of the urine from the umbilicus. In making a diagnosis 
 of these di^formities, reliance cannot be placed on objective 
 symptoms alone, and a physical examination of the parts 
 becomes necessary. The general relative appearance of 
 the external organs must be observed, aidetl by attempts 
 at passing a sound into the bladder and by the intro- 
 
DISEASES OF THE URETHRA AND HLADDER. 195 
 
 ductioii of the finger into tlu> rectum find, if possible, into 
 the vnginn. 
 
 Atresia of the urethra can only be cured by operation. 
 When there is entire absence of the urethra with the 
 existence of vesical fissure, or when there is persistence of 
 the sinus-uro-genitalis with partially developed urethra, 
 the production of an artificial oanal has been suggested. 
 
 Malformations of Kxe bladder follow the general rule, 
 and are thus in most instances due to some defect in the 
 normal process of development. Fissure is the most 
 frequent and prominent anomaly. It consists in partial 
 or complete absence of the anterior vesical wall, and is 
 usually accompanied by malformations of other organs. 
 It may be a simple fissure of the lower part of the 
 bladder, with an opening about three quarters of an inch 
 in breadth. A higher grade is that in which the fissure is 
 near the umbilicus, the lower part of the pelvic cavity and 
 the [)ubic symphysis being closed, and the lower part of 
 thi bladder, urethra, and external genitals normal. The 
 hir,hest grade {crsfrofilii/) is that in which the whole 
 anterior wall of tlu^ bladder seems absent, the inferior 
 abdominal region much shorter than normal, and the 
 umbilicus nearer the base of the pelvis. The abdominal 
 walls are divided, and the resultant fissure is filled up by 
 the bladder wall. The mucous membrane is puffed out 
 and red, and graduallj' merges into the skin of the 
 abdomen. On each side of the lower portion of the everted 
 bladder are situated the orifices of tlu' ureters. As a rule 
 the urethra is absent, and the clitoris is either divided, or 
 there may remain but a trace of it, or it may be entirely 
 absent. 
 
 Double bladder may be considered as extremely rare. 
 In such cases the double allantois, instead of forming one 
 passage, forms two, with a ureter opening into each. 
 Various explanations have been offered to account for the 
 malformation; some attribute it to defect in the allantois 
 
196 MEDICAL AND SURGIC.T. QYHMCOLr.i. 
 
 at an early period in embryonic life, some to a failure of 
 the pubic bones to unite; some to atresia of the urethra, 
 followed by over distension, the distended organ pushing 
 aside tirst the recti muscles, later the cartilaginous pubic 
 bones, and finally bursting, 
 
 Trcdtmcnt. In t}ie severer form no plan offers any 
 relief except a plastic oper^iion, find this is often only 
 palliative. Even under the most favorable circumstances 
 not much more can be done than to diminish the annoy- 
 ance which comes from the flow of urine over the 
 surrounding external surfaces. The operation which has 
 given most satisfaction consists in dissecting a flap 
 from the central part of the abdominal wall, immediately 
 above the fissure, and large enough to close in the bladder 
 completely. After vivifying the edges of the bladder 
 wall, the abdominal flap is turned down and the edges 
 stitched to it. A lateral flap is next taken from each 
 groin, and brought together with their raw surfaces in 
 contact with the raw surfaces of the central flap, and 
 stitched to it. 
 
 Irritable urethra. A case will occasionally be met 
 with, in which will be found pain and tenderness of the 
 urethra, frequent desire to urinate, and pain in doing so, 
 while a careful examination will fail to find any lesion. 
 It very commoidy follows catarrh of the bladder, or it 
 may be the result of exposure to cold, or of some 
 temporary or accidental irritation of the bladder. It may 
 be very effectually treated by dilating the whole urethral 
 canal with dressing forceps, or some form of dilator, the 
 operation being repeated several times. An application 
 of equal parts of carbolic acid and glycerine to the whole 
 canal will materially aid in effecting a cure, although 
 urination will be painful for several days after. 
 
 Urethritis. Urethritis is of three varieties, acute, 
 chronic, and gonorrha'Ml. Acute urethritis, though not a 
 very frequent disease, is a very distressing one, and often 
 
DISEASES OP THE URETHRA AND BLADDER. 
 
 1U7 
 
 difficult to relieve. In mnny cases it will be found to 
 depend upon a speoific cause, yet, like vaginitis, it is 
 sometimes uitfioult to mark the difference. Simple 
 urethritis comes on g/adually, and is often preceded 
 by symptoms of uterine or vesical disease, while the 
 gonorrh(Bal variety comes on rather abruptly, and is 
 preceded or attended by acute vaginitis and vulvitis. In 
 both varieties there is painful urination, and a sharp, 
 scalding sensation produced by the urine passing over the 
 tender surface. The desire to urinate is not so frequent, 
 or so urgent, as in cystitis, and in some cases the urine is 
 retained for a long time, dread of pain on the part of the 
 patient causing retention. During or immediately after 
 micturition, in some cases, a few drops of blood escape, 
 which may be recognized by its being exuded separately, 
 and not intimately mixed with the urine, as is usually the 
 case in hemorrhage from other portions of the urinary 
 tract. Examination will show the meatus swollen, red- 
 dened, and the urethral mucous membrane somewhat 
 prolajjsed. The urethra is felt as a firm, tender cord, and, 
 by pressure from above downward, a purulent fluid can be 
 pressed from the meatus, in which, if the gonocoecus is 
 found, reveals the nature of the urethritis. 
 
 Cystitis, a disease apt to be confounded with urethritis, 
 may be differentiated by using the catheter, and with- 
 drawing the urine direct from the bladder for the purpose 
 of examination. In the female, gonorrhoeal urethritis 
 frequently passes into the chronic stage, in which there 
 are no subjective symptoms, the diagnosis depending 
 wholly upon physical examination. A drop of thin milky 
 pus may be obtained by pressure upon the urethra from 
 behind forward, and the endoscope reveals the usual 
 appearances of inflammation. 
 
 The treatment, whether specific or otherwise, is con- 
 ducted on the same general plan. It consists essentially 
 in rest, a mild diet, the use of alkaline drinks, hot vaginal 
 
 1 
 
lyS MEDICAL AND SURGICAL OYN.EC()^OaY. 
 
 (loroln'H, warm sitz biiths uiul saiiim l(ixntivi\s. Much 
 boiiufit inny bo derived from doucOiin^ tho urothrn with 
 water as hot as can be borne. When the more acute 
 syniiytomiH have subsideil, injections of sulpliate of zinc 
 (1 to 509y, or of nitrnto of silver (1 to 4000), repeated four 
 to six times u day, will often prove useful. The injection 
 may be made with an ordinary uri^thral syringe, a pipette, 
 or a reflux catheter specially adapted for urethral irriga- 
 tion. In subacute or chronic cases, great benefit may be 
 deriv(>d from douching the urethra two or three times a 
 day, with hot water followed by the use of some astringent 
 solution, while internally, oil of santal wood in ten minim 
 capsules, or salol in five grain doses, may be administered. 
 
 Granular erosion. This very troublesome, but fortu- 
 nately rare affection may result from urethritis, or it 
 may appear without any previous disease. The mucous 
 membrane is found covered with young, imperfectly 
 developed epithelium, the papillre hypertrophied and 
 extremely sensitive, giving rise to most excruciating pain 
 during micturition, and afterwards keeping up a most 
 distressing tenesmus. In the treatment, mild measures 
 do not accomplish much. The best results will follow 
 dilatation of the urethra and painting the mucous mem- 
 brane with a solution of nitrate of silver, a dram to the 
 ounce, or of carbolic acid dissolved in glycerine. 
 
 Strictures of the urethra are far less frequent in the 
 female than in the male. They are for the most part 
 acquired, narrowing being extremely rare. The causes of 
 cicatrical contraction are chronic urethritis, most fre- 
 quently gonorrhcBal; injuries during childbirth, or other 
 forms of traumatism; caustic apjilications; and ulcers of 
 syphilitic or t\iberculous origin. The most satisfactory 
 method of treatment is by gradual dilatation, as practised 
 in stricture of the male urethra, by means of dilators, 
 similar to those used for dilating the urethra for diagnostic 
 purposes. -, ■ 
 
DISEASES OF THE URETHRA AND BLADDER. HM) 
 
 Prolapse of the urethral mucous membrane, ure- 
 thral caruncle and venous angioma hnvo nlnmdy boon 
 consiclorod wlion six^akiiij^ of (lisonsoH of tho vulvn, 
 (Ohap. XTV). 
 
 Urethrocele cousists of a PAOoulntion of tho middle 
 portion of tho urothrr. It is formod, most fnuiuontly, by n 
 bagging of tho inforior wall, tho ujipor wall (h^viating 
 little, if at all, from its normal ijosition. Tho symptoms 
 are, for tho most part, due directly or indirectly to the 
 retention of a certain amount of urine in the sac. The 
 residual urine becomes ammoniacal by decomposition, and 
 finally jjurulont. The sac wall becomes inflamed and 
 eroded, followed by general urethritis and perhaps cystitis. 
 The sacculation is susceptible to the touch and ocular 
 inspection, and when the pouch is large it protrudes from 
 tho vulva. 
 
 Trcdfmcnt. If the sac be of the diverticular variety, 
 with little urethritis, it may be wholly excised and the 
 resulting fistula closed by suture. In the presence of 
 much urethritis the sac should be left unclosed, to 
 facilitate drainage and the use of remedial applications. 
 After the parts have been restored to a comparatively 
 health}' condition, the fistula may then be closed. 
 
 Irritable bladder. Under this heading may be grouped 
 those conditions, either extrinsic or intrinsic to the 
 bladder, which are not sufficient to induce organic disease, 
 but which keep it in a constant state of irritability. The 
 symptoms are such as to lead to a diagnosis of cystitis, 
 but a careful examination shows the bladder to be normal, 
 and we are forced to ascribe the symptoms to simple 
 irritation of the peripheral nerves, either from direct or 
 reflex causes. Probably tho most painful form of irrit;»ble 
 bladder is that following plastic or abdominal operations. 
 Following coeliotomy, the urine is genqrally of high 
 specific gravity, has a heavy sediment, consisting usually 
 of amorphous urates and phosphatic crystals, and is 
 
200 MEIJICAL AN1> SURGICAL CIYN.ECOLOGY. 
 
 cupjiblo of prodiu^iiig gn^nt vcsic-iil irritability. Afti^r 
 Huch optirntioiiH too, tho uriiio is frcHiuoiitly diminiHluHl in 
 (pinntity, ho ns to HUggost tho poHsibility of noi^hritis or 
 obHtruction of one or both uretorH, n condition cnijabio of 
 aggrnvating tho bladder already irritated by tho heavily 
 charged urine. Irritability of the bladder will often be 
 found to be prt^sent as a reilex manifestation, in diseases of 
 the appendages, in dislocation of the bladder, in urethral 
 caruncle, in i)rolai)se of the rectum or of tho uterus, and it 
 often accompanies hysteria or other severe emotional 
 disturbances. The diagnosis can only be settled by 
 making a chemical and microscopical examination of the 
 urine; the former reveals nothing abnormal, the latter 
 a field laden with amorphous urates or phosphatic 
 crystals. 
 
 CYSTITIS. 
 
 Cystitis in the female is of frequent occurrence. It 
 may be either (trut(^ or chronie, local or (/cncral, and may 
 vary also greatly in intensity and duration, lasting from a 
 few days to many weeks The most frequent cause is the 
 introduction of septic matter into the bladder by means 
 of catheters, bougies, or other instruments. Cystitis, 
 caused by extension of an inflammatory process, is a 
 frequent result of vaginitis or urethritis, particularly of 
 the gonorrluDal type. Mechanical injuries, retention and 
 decomposition of urine, local chemical irritants, calculi 
 and foreign bodies, are all potent causes of vesical 
 inflammation. In the early stage of acute cystitis the 
 mucous membrane is red and congested, but otherwise 
 normal. Later the walls of the bladder become thickened 
 and the mucous surface covered with pus, fibrin, and 
 exfoliated epithelium, with, occasionally, small bleeding 
 areas, where the epithelium has become detached. In tho 
 chronic form the dangers are still more noticeable; the 
 muscular and fibrous coats are greatly hypertrophied, the 
 bladder cavity much decreased by the thickening and 
 
DISEASES OP THE URETJIRA AND HLADDEIl. 
 
 201 
 
 coiitraetioii of its wall, nml tho normal folds staiul out as 
 promituMit rid^os, and may cvcmi assiuiu> a polypoid form. 
 HtMiiorrlia^os occur into the mucous mtMiibranc and 
 appear as dark occliymotic spots, wliich latc^r cliango to 
 slate color from partial absorption. As a rule when, 
 cystitis arises from habitual over-distiMision, the bladdi^r 
 walls nrv thin and parohmi^nt-like. In these cases thii 
 diphtheritic and croupous type of intlammation is most 
 likely to occur. The entire mucous membrane becomes 
 extensively involved, and is covered with a layer of 
 Kbrous material, or false membrants which may be thrown 
 off as a complete cast of the bladder. In more severe 
 cases of diphtheritic cystitis, the membrane is composed, 
 not oidy of necrotic mucous membrane*, but also of the 
 muscular coat. In some cases the diphtlu^ritic process 
 becomes locali/Anl and deep erosions or ragged ulcers 
 result. 
 
 The urine is usually intensely alkaline and heavily 
 laden with mucous and urinary salts, especially the 
 phosphatic, and are often dt^posited as tine incrus- 
 tations on tlie ulcerated areas. Microscopically, there 
 will be found a large number of leucocytes, or red 
 corpuscles, pavement epithelium, isolated, or in clumps, 
 and often large numbers of crystals of triple phosphates. 
 As a result of the hypertrophic thickening of the bladder 
 walls, the vesical orifices of the ureters may be partially 
 occluded, and dilatation of the ureters, pyonephrosis or 
 hydronephrosis may result. 
 
 Symptoms. The symptoms will vary according to the 
 cause, extent, severity and stage of the inflammatory 
 affection. In the acute stage, pain, often severe, is felt 
 above and behind the pubes, and radiating into the groin 
 and down the thirhs. The desire to void urine is almost 
 constant, and the act is attended by s-harp lacinating i ain 
 at the base of the bladder. Follovang urination there is 
 usually a sensation as though a few drops of urine yet 
 
 L 
 
202 MEDICAL AND SUUOICAL GYN.ECIOUHIY. 
 
 romniiK^tl, ii (^(uiditiori soinor^'U^H so urj^iMit an to <'(iuho tlio 
 pationt to remain for liourH on tlio ohainbor. Thoro in 
 often n dull pnin in tho pcrin(>um, and proHHuro over the 
 pubos will incrri'aso tho i)ain or tenderneHH tlu^re. Fre- 
 quency of micturition iH an invariable .^ymptom, tlu^ 
 frecpuMicy deijendin^ upon the dej^nn^ or Hta^e of intlam- 
 mation. Hematuria is not uncommon in tlu» early wtage, 
 and at times there appearH to be little less than pure 
 blood voided; but as tho process becomes older it entirely 
 disappears. In the acute form, the (piantity of urine 
 passed may be normal, or slightly incn^ased, tho color 
 unchanged, and possessing feeble acid reaction. After 
 standing a few hours it becomes alkaline, and precipitates 
 a diffuse sediment containing mucous, pus, and blood, in 
 greater or less amounts. Sometimes the urine becomes 
 ammoniacal and extensively offensive. The attack is 
 often ushered in by a chill, followed by a rise of tempera- 
 ture, which soon subsides, but in more severe septic or 
 diphtheritic cases, tlu^ symptoms from tho onset indicate 
 a very gravis condition. The patient falls into a typhoid 
 state, with dry tongue, headache, vomiting, subsultus 
 and delirium. Urination is sometimes obstructed by 
 fragments of membrane, causing over-distention, or the 
 ureters may be obstructed, producing total suppression 
 and death from uraemia. In chronic cystitis, the symp- 
 toms referable to the organ itself, and its contents, are 
 similar to those described, but of a milder type. Tho 
 urine contains pus, mucous, and exfoliated epithelium in 
 large amount. On standing, it precipitates an extremely 
 tenacious sediment, is neutral or alkaline in reaction, 
 and sometimes fetid. A careful examination with the 
 endoscoije will reveal the evidences of inflammation and 
 ! j; the pathological changes present. 
 
 Treatment. Especially important is the prophylaxis 
 of vesical inflammation. A large proportion of cases arise 
 from the introduction of pyogenic organisms into the 
 
UlSliASES OF THE UUETHUA AND ULADDlilt. 20,3 
 
 l)la(l(lor, honco too much cnro cannot be oxerciHtnl in 
 clonnHinj:? and Htorilizin^ all inHtrumt>ntH uhihI for (examina- 
 tion or tri'atmcnt. Tho first (^HHiMitial in rent i.. bed until 
 the acuto HymptoniH have HubsicU'd. The diet should bi^ 
 .instimulatin^; Huid and Hemi-fluid foods, such as milk, 
 eggs, and light broths, are most suitable. Saliiu^ laxatives 
 should be admiiiistered, and cnre tnkou to keep the large 
 intestine free from fecal accumulation. Warm vaginal 
 douches and em^mata nre very soothing, and hot sitz 
 baths, with hot local compresses, will relieve thc! tenesmus 
 and V(esical fulness. To allay the fever, and to render the 
 urine unirritating when acid, the admiidstration of the 
 following mixture will be found usef d, osijocially when 
 combined with copious alkaline draughts: 
 
 R. PottvHS. Citrat., oz. h.«; 
 Spts. yEther Nit. , oz. i ; 
 Tiiict. Aconit., drains iss; 
 Atiuii' ad., oz. viii. M. 
 
 Sig. — Tablewpooiiful in some water every four hourw. 
 When the urine is alkaline it may be rendered acid *>y 
 the administration of benzoate of ammonia, in tei- grain 
 doses, every three or four hours. Salol is particularly 
 useful in ammoniaeal decomposition, giving five to *ni 
 grains every four to six hours. The same may be said of 
 boric acid, in ten to tifteen grain doses. To control jjain, 
 opium, belladonna, hyoscyamus, or chloral may be used 
 with caution, and when prescribed should be given by the 
 rectum. The first three mentioned are best administered 
 in the form of suppositories, while chloral gives the best 
 results when dissolved in two or three ounces of starch 
 water, and administered as an enema. One of the most 
 suitable preparations of opium to be given by the mouth, 
 is Dover's powder, but bromide of soda, in twenty grain 
 doses, and repeated every four to six hours, often acts 
 more kindly for the relief of pain and tenesmus. Cannabis 
 indica will often subdue the pain quite as effectually as 
 opium, and with less injurious after effects. Irrigation 
 
204 MEDICAL AND SUliGICJAL GYN.ECOi^OGY. 
 
 of the bladder may be resorted to when the acute 
 symptoms Imve subsided, or earlier if it is of septic origin. 
 The most useful solutions for that purpose are three per 
 cent, boracie acid, one-tenth to one-half per cent, nitrate 
 of silver, ono-tenth to one-third per cent, permanganate 
 of potash, one-half per cent, creolin, or one to ten 
 thousand bichloride. 
 
 In chronic (cystitis special attention must be paid to 
 the general health, opium is to be avoided if possible, the 
 bromides or cannabis indica being used instead to relieve 
 tenesmus. Alkaline reaction of the urine should be cor- 
 rected as in the acute stage and, if the urine be purulent, 
 benzoic acid will be found of most service. Of the balsamic 
 preparations there is none better than pure oil of santal- 
 wood, administered in ten minim capsules every four 
 hours. The treatment consists mainly in local measures, 
 in the form of vesical irrigation by means of some simple 
 form of irrigator. The quantity to be injected at one 
 time must depend upon the character of the solution and 
 the degree of vesical irritability ; in some cases an ounce 
 is all that will be retained. The maximum volume shovdd 
 rarely exceed two to four ounc^^s. the process being 
 repeated several times until the bladder is thoroughly 
 cleansed. The temperature of the tluid should be from 
 UX)° to 105° F., and the irrigating process repeated twice 
 daily. Besides the solutions already mentioned, other 
 remedies have been found very serviceable, such as 
 salicylate of soda, a dram to the pint; methylene blue, 
 one to two grains to the ounce, especially in purulent 
 cases; ichthyol in water, one-half to one per cent., especi- 
 ally in gonorrhceal cystitis. In rebellious cases a two per 
 cent, solution of rescicin may be employed. Iodoform, 
 in the form of an emulsion (iodoform fifty parts, glycerine 
 forty parts, mucilage of acacia ten parts), has been highly 
 recommended, from two drams to an ounce being injected 
 once a day. When treatment fails and the pathological 
 
DISEASES OF THE URETHRA AND BLADDER. 205 
 
 procoss j^rows worHo, it may be nooessnry to Hocuro 
 coustaut drainage of tlie bladder by means of dilatation of 
 the urethra, by tlie formation of a vesico-vaginal fistula, 
 or by the use of a self-retaining catheter. The most 
 satisfactory method for draining the bladder is by the 
 formation of a vesico-vaginal fistula. 
 
 KmmcVi^ operation. A sound is first passed into the 
 bladder, and the vesico-vaginal wall steadied with a 
 tenaculum and incised, after which a pair of uiunt-pointed 
 scissors is entered and the opening tmlarged. To prevent 
 the fistula from closing, the vesical and vaginal mucous 
 mi^mbrane should be stitched together. Instead of the 
 knife or scissors, the Paquelin cautery may be used. 
 
 Vesical Calculi. Stone in the bladder is a far less 
 common ilfection in the female than in the male. They 
 are oftener of the phosphatic variety, roughened areas of 
 the bladder wall being liable to become encrusted, and 
 serve as the starting point for calculous formation. The 
 stone usually lies free in the cavity; rarely it is encap- 
 suled. When suspected the diagnosis can readily be made 
 by the sound, by a cystoscopic examination, bj' digital 
 exploration through the urethra, or by conjoined abdom- 
 inal and vaginal palpation. 
 
 Treatment. Calculi may be removed by way of the 
 urethra, or by vpgiiml or suprapubic cystotomy. Small 
 calculi may be removed through the urethra, after dilata- 
 tion by n ^>ans of slender forceps. Larger, friable stones 
 may be crushed with a lithotrite, and the debris washed 
 out through a ^ "ethral speculum. When cystotomy is 
 required, the vaginal operation is generally preferred as 
 the simplest and safest. 
 
 Foreign bodies introduced by accident, or intentionally, 
 may be found in the urethra or bladder. The diagnosis 
 may be made in the same way as in calculus, and their 
 removal may be accomplished through the urethra. 
 
20(i MEDICAL AND SURGICAL GYNECOLOGY. 
 
 Neoplasms of the female bladder are of infrequent 
 occurrence. They include papillomxi, mijxomd., jibvomd, 
 mijoma, sarcoma, cpitlu'lioma, and carcinoma. The most 
 constant symptom of vesical neoplasm is hematuria. 
 Growths at ^' 3 vesical neck give rise to frequent and 
 painful urination, and may interrupt the flow of urine at 
 micturition, or cause retention. As a rule cystitis sooner 
 or later results, followed by urethritis and pyelo-nephritis. 
 An examination of the urine will show it to contain pus, 
 blood, mucous, epithelial scales, neoplastic shreds and 
 phosphates. The diagnosis is made by conjoined abdom- 
 inal and vaginal manipulation, by the cystoscope, or by 
 direct examination through a speculum. 
 
 Treatment. Many small growths which are peduncu- 
 lated, may be twisted off and removed through the urethra. 
 If the tumors be sessile and spread out over the mucous 
 surface it is best to resort to the curette. If the hemoi- 
 rhage is free, or persistent, the bladder may be irrigated 
 with hot water, and the vagina tightly packed with gauze. 
 If the tumor be too large for removal through the urethra, 
 vaginal cystotomy should be performed. If the tumor be 
 malignant, it may be curetted and lightly cauterized, 
 which will have the effect of greatly alleviating the 
 patient's suffering. If the urination be painful and a high 
 grade of cystitis present, the vaginal incision should be 
 left open to allow for free drainage. 
 
 Diseases of the ureters. The ureters are liable to 
 ascending diseases from the bladder, to secondary involve- 
 ment, or to descending diseases from the kidney, or to 
 diseases which begins primarily in the ureter itself. One 
 or both ureters may be affected. A serious att'ection of 
 both ureters is incompatible with long life, as sooner or 
 later .secondary changes occur in the kidneys. As a result 
 of ureteritis, of whatever form, the ureter of the affected 
 side becomes enlarged and may be palpated through the 
 antero-lp.teral wall of the vagina in its upper third, where 
 
DISEASES OF THE UTERUS — MALFORMATIONS. 207 
 
 it gives to the finger the sensation of n rigid cord, or the 
 feel of n round lead pencil. It is extremely sensitive upon 
 pressure, and when so compressed produces a strong desire 
 to urinate. An enlarged ureter can readily be felt by the 
 rectum, from the broad ligament up as far as the pelvic 
 brim. Further examination may be made, and much 
 information derived, from the use of cystoscopy and the 
 ureteral catheter and probes. 
 
 The treatment should consist in curing the cause 
 which produces the ureteritis; co-existing cystitis should 
 be managed in the usual way, morbid urinary conditions 
 corrected and the urine rendered antiseptic by salol. Fre- 
 quent vesical douches and high rectal enemata of warm 
 water should be employed. With the use of Kelly's spec- 
 ulum *\\e ..i-eteral injections may be repeated, at suitable 
 intervals, provided the operator has acquired the necessary 
 technique for the introduction of those instruments. 
 
 CHAPTER XIX. 
 
 DISEASES OF THE UTERUS. 
 MALFORMATIONS. 
 
 All the important anomalies of the uterus result from 
 arrest of development, and the nature of these anomalies 
 depends, in a great part, upon the time at which the 
 development was arrested. By bearing in mind the 
 history of the normal development of the uterus, the many 
 abnormal forms will be more readily understood. If the 
 arrest of development occurs at a very early period, there 
 will be simply a rudimentary bundle of muscle to indicate 
 its situation, and in extraordinary cases there may be 
 entire ab.senco of the organ. If there is arrest of f sion 
 of Muller's ducts before the twelfth week, a more or less 
 
208 MEDICAL AND SURGICAL GYNiECOLOGY. 
 
 duplex uterus must result. If there is arrest of fusion in 
 the two cnnnls after the twelfth week, a bicornate or sep- 
 tate uterus will result. If the disturbance of development 
 
 occurs at a later period, 
 the uterus will retain a 
 fwtal or infantile form, 
 without longitudinal sej)- 
 aration or distinct indi- 
 cation of the duplex man- 
 ner of its formation. 
 
 For convenience of de- 
 scription, malformations 
 can thus be divided into 
 those due to arrest of de- 
 velopment during the 
 first half of intra-uterine 
 life; and those due to 
 arrest of development 
 after the first half of 
 intra-uterine life. 
 
 Malformations from 
 ^ , arrest of development 
 
 FiG.sg. — Development of the genito-iirinary tr.-ict . 
 
 in the feniale.—w, «, kidneys ; e, i; ureters ; during the firSt half Of 
 
 a, their orifices ii] the bladder ; 711, 7u, WolfTian 
 
 bodies; {?,?, their efferent ducts; /,/», their mtra-Utenne life. Ah- 
 
 openings into the urethra ; ^, ^'i ovaries ; »i,i>i, 
 
 ducts of Muller ; 0, their common orifice ; 7', SCUCC OV VlKUIHCIlldVll ('('- 
 
 iiro-genital sinus ; i/r, urachus ; c, clitoris. 1 ,• 11 1 
 
 velopmcnt oj the uterus. 
 Complete absence of the uterus is an extremely rare 
 occurrence, but rudimentary development is not un- 
 common. There may be a small, solid, muscular body, 
 without a cavity, or a partial excavation, or it may consist 
 of a membranous sac. The vagina is usually absent, or 
 consists of a shallow depression. Usually the tubes and 
 ovaries are ill developed, and menstruation absent, but in 
 cases where they are developed, periodical activity 
 occurs in them, which, being unrelieved, causes much 
 suffering. 
 
 o 
 
DISEASES OF THE UTERUS — MALFORMATIONS. 
 
 20<) 
 
 Uterus unicornis results from nn arrest of development, 
 or from failure to appear, on the part of one of Muller's 
 ducts. The developed side is situated entirely on one side 
 
 Fit;. 60. — Uterus unicornis with rudimentary horn. LH, left horn ; RH, right 
 rudimentiiry horn ; I.o, .ind Ro, left and right ovary ; l< Lr, and R Lr, left and 
 right rouiui ligament ; LT, and RT, left and right tnhe. 
 
 There is 
 
 of the axis of the pelvic cavity, and it inclines quite 
 strongly towards the corresponding pelvic wall 
 no uterine fiiiidns. 
 the uterine body end- 
 ing in a cone-shaped 
 projection, in which 
 is inserted the Fallo- 
 pian tube. 
 
 Uterus hicornis 
 and uterus didelplnjs 
 result from the want 
 of union of Muller's 
 ducts immediately 
 below those portions 
 which normally forir 
 the Fallopian tubes. 
 The want of union 
 may be confined to 
 the neighborhood of 
 the tubes, leaving a 
 slight depression in 
 the fundus, or it may extend lower down, dividing a large 
 part of the uterus. 
 
 Kit;. 61. — Didelphic Uterus and Divided Vagina : a, 
 right segment ; /', left segment ; c, rf, right ovary 
 and round ligament ; /, e, left ovarj; and roiuid liga- 
 ment ; g, j, left cervix and vagina ; k\ vaginal 
 septum ; //, /, right cervix and vagina. 
 
210 
 
 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 Fig. 62.— Uleriis Duplex. 
 
 UtcruH <luph:r. The double uterus results from n 
 wnnt of union of Muller's ducts ns far as the vagina. 
 
 in consequence of which 
 two uteri have developed. 
 One Fallopian tube is 
 attached to each uterus, 
 and the vagina and cer- 
 vix may, or may not be 
 double. 
 
 Uterus septus, or two- 
 chambered uterus, arises 
 from an imperfect union 
 of Muller's ducts. The 
 uterus is of normal shape, 
 but the septum has not been obliterated. The vagina is 
 apt to be similarly divided. When the septum lias been 
 partially absorbed it is called nterus suhseptus. 
 
 The diagnosis of these de- 
 formities usually requires the 
 aid of an anaesthetic. With 
 the thumb in the vagina, and 
 the finger in the rectum, the 
 structures between them may 
 be palpated, especially if the 
 uterus is drawn down with a 
 vulsellum, toward the vaginal 
 outlet. A sound introduced 
 into the uterine cavity will 
 also aid materially in arriving 
 at a correct conclusion. In 
 such cases treatment is of no 
 avail, except as far as reliev- 
 ing painful or distressing 
 symptoms. Where there is absence or rudimentary 
 development of the uterus, removal of the ovaric^s may be 
 demanded in order to secure relief. 
 
 Fk;. 63. — Twci-chambered uterus. 
 
DISEASES OF THE UTERUS — MALFORMATIONS. 
 
 211 
 
 Atresia uteri. Just as has been shown that the hymen 
 or vagina may be closed, the uterine canal itself, although 
 more rarely, may be the site of atresia. The mucous 
 membrane of the vagina may cover the whole vaginal 
 portion, without forming any external os, or the cervix may 
 form one uninterrupted muscular mass without bore. In 
 such cases the vaginal portion may be well developed, or 
 totally absent. In a bicornate uterus, one horn may be 
 closed. Whenever the genital canal is closed, the symp- 
 toms due to retention, such as amenorrhoja, painful 
 menstrual disturbances, and the 
 formation of a tumor will be 
 present, hence tin; remarks 
 made upon the symptoms, 
 diagnosis, and treatment of 
 atresia of the hymen and 
 vagina are applicable to atresia 
 uteri. When the atresia is 
 situated in the uterus, however, 
 the vagina can be exposed to 
 its full extent and, in so doing, 
 the uterus will be found to form 
 a round elastic tumor above it. 
 
 Dicujnosis. In pregnancy there will probably be a 
 history of menstruation, and there will be present some of 
 the well known signs. A fibroid forms a hard, nodular 
 tumor, and often causes menorrhagia. Hematocele 
 appears suddeidy, forms a broader mass, which pushes the 
 uterus forward, and with these there will be a history, 
 possibly, of previous menstruation. If the uterus is 
 double the atresia is found much more frequently on the 
 right side. In such cases the tumor will form in one 
 uterus, while the other may perform the menstrual 
 function quite normally. 
 
 Treatment. If the uterus is single, an opening should 
 be made through the cervix with a trocar, or blunt-pointed 
 
 Fk;. 64. -Atresia of ihe cervix uteri. 
 
212 MEDUJAL AND SURGICAL OYNiECOLOGY. 
 
 forceps, ftiid (Milarged if uocessnry, and the contents 
 evacuated witli the same care as already described wlien 
 speaking of the treatm(^nt of atresia of the hymen, after 
 which the uterine cavity must be irrigatt^d with an anti- 
 sejjtic solution, and somc^ strips of iodoform gauze loosely 
 inserted, and brought out through tlie now formed os. 
 Later on the interior of the uterus may be curetted to 
 combat endometritis and to hasten involution. 
 
 If the accumulation is found in one half of a double 
 uterus it is still an advantage to enter, if possibh\ tlirough 
 the cervix; but often there is no choice, and the tumor 
 must be punctured at its lowest point in the vagina. If 
 the swelling cannot be reached from the vagina, cceliotomy 
 should be performed, and the affected horn or whole uterus 
 removed. 
 
 Arrest of development during the second half of 
 intra- uterine life. Fetal and infantile uterus. Some 
 adult women have a uterus which corresponds in size to 
 the uterus of a fcotus toward the end of pregnancy, or that 
 of a young chihl. Other organs may be normal, but often 
 the condition is combined with other abnormalities, 
 especially of the ovaries. 
 
 Pul)escent or con(/enitally atrophic uterus is one 
 characterized by its small weight, often not exceeding an 
 ounce, but the cervix and body have abo' t the same 
 length. Sometimes the body of the uteras is well 
 developed, but the cervix is small, pointed, or conical. In 
 exceptional instances, the whole vaginal portion may bo 
 lacking, while the rest of the vaginal apparatus is well 
 developed. In those cases the vagina i^asses directly into 
 the uterine cavity by a small constricted canal. Anteflex- 
 ion of the uterus is often congenital, and simply a contin- 
 uation of the shape of the uterus found in the fa3tus and 
 in young children. The uterus may congenital ly bend to 
 one side, the two Mullerian ducts not having kept pace 
 with one another. 
 
DISEASES OF THE UTERUS— INJURIES. 
 
 213 
 
 CHAPTER XX. 
 
 DISEASES OE THE UTERUS CONTINUED. 
 INJURIES. 
 
 On account of its position, tlui unimpro^unted utoriis 
 is littlo exposed to iujurios from without, but is frequoritly 
 the Hoat of injuries produced through t lo vagina. In 
 gyn.'Dcological operations the uterus m occasionally 
 wounded. Some uteri are so soft that they are easily 
 penetrated by the sound or dull wire curette. When 
 strict antiseptic precaution have been observed, and in- 
 jection of an irritating tluid omitted, no evil consequence 
 will probably follow a small puncture of the uterus. If 
 there is prolapse of the intestine, cceliotomy should bo 
 performed, the intestine drawn up and the opening closed 
 in the uterus. 
 
 Laceratio.i of the cervix. By far the most common 
 injury to the uterus is that sustained by the cervix during 
 child-birth, when it may be 
 ruptured, or lacerated. The 
 important pathological bearings 
 of this accident upon disorders 
 of the uterus have been appre- 
 ciated only of late years. The 
 credit of having recognised the 
 significance of the lesion, and 
 of having furnished a safe and 
 efficient means for cure, belong 
 to Dr. T. A. Emmet. 
 
 Ctuiscff. The rapid forcing of the presenting part of 
 the child through an imperfectly dilated cervix, brought 
 about by early riipture of the membranes, or unusually 
 severe and protracted expulsive efforts, is the cause, in a 
 large proportion of instances, of laceration. More or less 
 important parts in the causation of this injury are played 
 
 Fig. 65.— Unilateral laceration of the 
 cervix. 
 
211 
 
 MEDICAL AND 8UR(tICAL OYN.ECOLOOY. 
 
 by rigidity, faulty {lovolopmctit, cystic disonHc, cicatricijil 
 
 iiidunitiou. and liyporplaHia of the corvix. The uimkillcd 
 
 U80 of obstetric forceps may also be a cause of tln^ accidiMit. 
 Lacerations are called pdrtial whiui the tear in the 
 
 canal do(»s not reach the mucous membrane of the vagiim; 
 
 complete, wlien the whol(> thickness of tlu^ cervix is torn. 
 
 Complete laceration may be uniUiteral, hiUitenil, or 
 
 stcUdte. 
 
 Bihiferal lacerations are by far the most common, and 
 
 they almost always extend from side to side, rarely from 
 
 before backward. 
 
 Unihiievdl lacerations may occur in any part of the 
 
 cervix, but are more common on the left side, owing, it is 
 
 said, to the frequency of the 
 first position of the vertex. 
 
 Stelldte lacerations, while 
 sometimes not deep, are 
 often of considerable extent. 
 In regard to frecjuency, it 
 may be said that but few 
 women confined at full term 
 
 Fig. 66.-Bilaterall.-.ceration of the cervix, wilh CSCapC withoUt SUStaiuiug 
 ever.ionoflhecervical,nucousn,eml,rane. ^^j^^^ j^^.^^^, ^^ ^j^^ ^^^^j^^ 
 
 be it ever so slight, but the proportion of rents likely to 
 produce pathological symptoms, may be put down as 
 somewhat less than fifty per cent. 
 
 After laceration, the torn surfaces, bathed in the lochia, 
 rarely unite, and in that condition will act as a source of 
 irritation, jirevent p r involution of the uterus, and 
 will eventually indue enlargement and thickening of the 
 uterine tissues. In some cases the flaps become enor- 
 mously hypertrophied by the formation of new connective 
 tissue, so as to resemble small fibroid tumors, and have 
 been mistaken for such. Relaxed ligaments with uterine 
 displacement — especially when it is associated with a 
 lacerated perineum— and congested ovaries and tubes, in 
 
 
 A 
 
 jfiiim 
 
 mm^!il'!l!l^l^*" 
 
 ^ 
 
 i 
 
 f, 
 
 
 
 %% 
 
 i 
 
 
 -((//)(/, i*ff'j^B 
 
 
 \ 1 
 
 ~a 
 
 1 
 
 lA 
 
 
 // 
 
 
 
 
 ^ 
 
DIHEASES OF THE UTERUS— IIJJUUIES. 
 
 215 
 
 tlu'ir turn, follow. OccnHiomilly imtJirc H(>t'ins to inak«^ uii 
 
 effort to rc^pair tlui hKu^rntioii by tlu^ t'orinntioii of a hirgo 
 
 amount of granulation tissui^ tilling up tho angloH of tho 
 
 rent. Ill process of time this granulation tissui^ becomes 
 
 converted into a hard dense cicatrix, compressing terminal 
 
 nerve Hlaments, a condition thouglit by many to be the 
 
 cause of the reflex symptoms so commonly met with in 
 
 long standing cases. When the lacerated cervix does not 
 
 cicatrize, the separated lips evert, the mucous membrane 
 
 lining the cavity is rolled out (ectropion), its epithelium 
 
 is gradually rubbed off, and a hyperplasia of cysts and 
 
 papilhu take place, giving rise 
 
 to a profuse, discolored, glairy 
 
 discharge. This hyperjbmic 
 
 a n d hyperlastic condition 
 
 often extends ujjward to, and 
 
 often beyond the internal os, 
 
 and cervical and corporeal 
 
 endometritis result, so that 
 
 menorrhagia may be present. 
 
 Attention has been calhid to 
 
 the frec^uency with which 
 
 epithelioma of the cervix has 
 
 been found in conjunction 
 
 with laceration, and it is 
 
 undoubtedly a fact that a very large proportion of such 
 
 cases are preceded by such traumatism. 
 
 Symptoms. Tho symptoms which attract the attention 
 of the patient will probably be a dull pain in the back, 
 sacrum, and lumbar regions; bearing down or dragging 
 in the pelvis; pain in the ovarian regions, hips and thighs; 
 leucorrhoea; menorrhagia; and occasionally sterility, or 
 habitual miscarriages. Accompanying these there will 
 generally be found progressive loss of health, and a most 
 decided state of anaemia. Neuroses of the eyes, head, 
 stomach, and bowels are also frequently met with; to 
 
 Fig. 67. — Multiple stellate laceration of 
 cervix. 
 
21() MEDICAL AND SUUOICAL <lYN.ECOL()GY. 
 
 which hyHtc'^-icnl Hymptoms may ovon bd mldiHl. On 
 pnHHiii^ the Hiig(^r into i\w vagina, tho hicoration in oawily 
 ro(M)gni/-('(l. In tho angh'H of tho ront hanlonod tinHUo is 
 foit, i)roHHuro upon whicli product^H [)fiin, wlii(!h ofton 
 rndinti^H into tho pt^lvis and down tho thighs. Tlio Hurfnco 
 may fool rough and granuhir from tho largo follioloH, or 
 volvoty and soft from orosion. Kxamination by spocuilum 
 dooH not givo mu<Oi information, furthor than to bring into 
 view tho granular or orodod Hurfaco, tho whito or yollowish 
 dlHchargo with whicih it is covorod, and tho hyportrophiod 
 condition of tho cervical flaps. 
 
 Indications for trachelorrhaphy. Tho moro oxistonco 
 of a lacc^ration does not call for radical operation. Tho 
 indications for that moasuro depend entirely upon tho 
 depth of tho rent, tlu^ degree of oversion and amount of 
 orosion and hyporijlasia of tho torn lips; tho intensity of 
 tho symptoms depending upon it, and by tin* improbability 
 of these .symptoms b(ung permanently cured by other than 
 radical treatment. The treatment of laceration immedi- 
 ately after their occurrence has boon strongly advocated 
 by some, but such a procedure has not gained in favor 
 with the majority of obstetricians, owing to the difficulty 
 in estimating tho extent of laceration, the relation of the 
 parts, and the ability to bring them together properly. 
 
 Prcliminarji frcafmcnt. Some have thought it advis- 
 able to cure orosion. when present, before operating, but 
 such a procedure does not seem necessary. If there is 
 extensive cystic degeneration, it may be treated for a 
 time by local applications, but generally both these 
 conditions can be managed at tho time of operation. 
 Preparatory curettage of the uterine cavity has also been 
 advised when endometritis exists, but this too is un- 
 necessary as it can be done just as effectually before 
 beginning the denuding process. 
 
 The operation of trachelorrhaphy may be performed 
 by placing the patient in the dorsal position, the legs 
 
DISEASES OP THE UTER'JS— IN.Il'KIES. 217 
 
 elovnt(Ml, mid kepi in poHition by Clovcr'H crutch, nrul n 
 
 Sims" brofid-bliKlccl Hpcciilum itiHcrtcd. A very convciiii'iit 
 
 Hpcculurn for that niid other opi nitioiiH on tlie utcruH, 
 
 when the pnti(Mit is in tlic dorHnl i)o.sition. in oi.o known 
 
 (iH Fidc^bohl's. It is HO curved at the junction of the 
 
 haiuUe jind the blade that it will not slip out. and. by 
 
 HUH[)ending a HufficicMit weight to the handle, the neceHsary 
 
 retraction is made on the perineum, and the necessity for 
 
 an assistant to hold the si)eculum df)ne away with. Sumo 
 
 prefer oijcratinj^ in Sims" position, claiming that it ^ives 
 
 much mon> room for manipidation 
 
 and for the piissage of the needles. 
 
 However the choiv'^e of position and 
 
 speculum is largely .^ matter of <»du- 
 
 cation and habit. Th > best needles 
 
 to employ are heavy triangular or 
 
 bayonet-pointed, straiglit. or curved 
 
 Slightly at tlie point (Emmet's). The 
 
 suture material is a matter of in- p, -„ vii m- .^ „i,.n, 
 
 rlG. 00. — Kdebonl s speculum. 
 
 difference: silver wire, silkworm, silk 
 
 and catgut are all used, If the perineum is to bo closed 
 at the same time, it is best to use some material which 
 will be absorbed in the course of eight or ten days, such 
 as chromic catgut. Unless contraindicated from some 
 good cause, it would be preferable to use catgut under 
 all circumstances, as most patients have a great dread 
 of what they look upon as another operation for the 
 removal of the stitches. 
 
 After deciding upon the amount of denudation neces- 
 sary, the edge of one lip is seized with a tenaculum, and a 
 Hap raised from the surrounding tissue with scissors or 
 scalpel, the cutting process being continued until tlie 
 angle is reached, where it may be necessary to go (piite 
 deeply to remove all the cicatricial tissue. After the 
 angle has been passed, denudation is made in a similar 
 manner on the other lip, and completed by uniting it with 
 
218 
 
 MEDK^AL AND SURGICAL GYN.flOOLOOY. 
 
 the previous incision. If n second laceration exists on the 
 opposite side, it is to be denuded in the same way. Some 
 use a peculiar pair of scissors devised by Skene and known 
 as " hawk-bill " scissors, wliich denude the margins and 
 take out th(> cicatrix at one and the same time. Hemor- 
 rhage can usually be controlled by hot water, but if very 
 troublesome a stitch may at once be jjassed through both 
 lips of the cervix, above the angle, and tied so as to com- 
 press the circular artery. The sutures are next introduced, 
 the first being passed through the upper angle of the rent, 
 and each successive one through the whole depth of each 
 
 Fir,, fig. — Surfaces Jenuded and sutures passed. 
 
 Fk;. 70— Same with sutures lied. 
 
 lip, until all the sutures needed for that side have been 
 inserted. Next the sutures on the opposite side are 
 similarly inserted, if the denudation has been bilateral, 
 after which they are tied, the highest one first. A sound 
 is next introduced into the cervix, to mrke sure that it is 
 sufficiently patulous. After flushing and drying the 
 vagina, it may be lightly packed with strips of iodoform 
 gauze. 
 
DISEASES OF THE UTERUS — METRITIS. 211) 
 
 CHAPTER XXI. 
 
 DISEASES OF THE UTERUS CONTINUED. 
 METRITIS. 
 
 According to the etymology of the word, metritis 
 means iriHnmnintion of the uterus, but tlie classitiontion of 
 the various patliolo^ical conditions included under that 
 heading is not so easily disposed of. When considered 
 according to the progress of the disease, it is designated 
 by the terms acute and rhrouic ; when classifi(^d according 
 to location, it is divided inio cervical rw\ corporeal: when 
 looked at from r^a etiological standpoint, it is designated 
 by the terms pucrperah post-puerperdl, <ionorrh(ral, 
 exanthematous. and traumatic; or when from a patho- 
 logical standpoint, (jrannlar. fuiajous, and ulcerating. 
 
 For convenience of description the various forms of 
 endometritis may be classified as follows: 
 
 1. Acute metritis and acute endometritis. 
 
 2. Chronic cervical endometritis. 
 
 3. Chronic corporeal endometritis. 
 
 4. Chronic metritis, or subinvolution and sclerosis. 
 
 ACUTE ENDOMETRITIS AND ACUTE METRITIS. 
 
 By the term ; :ute endometritis i.s meant acute in- 
 flammation of the endometrium, and by the term acute 
 metritis, inflammation of the walls of the uterus, but as 
 inflammation of the endometrium can scarcely occur 
 without the uterine walls participating to some extenc. nor 
 can inflammation of the walls occur v .thout participation 
 of the mucosa, the description of the two. as distinct 
 diseases, would be usel(>ss. at least from any other *han a 
 pathological standpoint. When the inflammation affects 
 the mucous membrane more than the walls, it is termed 
 endometritis; when it produces extensive changes in the 
 walls, it is called metritis. 
 
220 MEDICAL AND SURdUUL (lYN. ECOLOGY. 
 
 (^(iiixcs. Tlu' luost poti'ut fuiisf )lriH(^s from bnctorinl 
 invasion from iafccti'd Imiuls and instruments (luring 
 parturition, abortions, operations and examinations: during 
 uterine and vaginal douches; from retained deoidua after 
 abortion: or from invasion of the gonococcus. Infc^etion 
 may arise seeomhtrily from foreign bodies K'ft in the 
 uterus or vagina, such as stem pessaries, tents and tampons. 
 Violent congestion of the uterus, such as occurs in acute 
 suppression of menstruation, and the prolonged conges- 
 tions growing out of flexions and versions, are prominent 
 factors in these lesions. Retained menses, arising from 
 stenosis, catching cold, and other influences, such as over- 
 exertion, excessive coitus, or traumatism, acting during 
 the menstrual congestion, increase the natural hyperaMnic 
 condition to such an extent as to interfere with its natural 
 subsidence, and tend to engorgement and inflammation. 
 Specific germs of the exanthemata appear to be capable of 
 inducing mild inflammatory changes upon the mucous 
 membrane of the entire uterus, seeming to act upon it as 
 upon other mucous tracts (the conjiinctivfv for instance 
 during measles), and in a similar manner tend to disappear 
 with the subsidence of the disease. 
 
 Pafholoc/ii. In acute endometritis the extent of the 
 lesion will de})en(l upon the virulence and activity of the 
 infecting element, and will vary from a mild injection of 
 the endometrium to a deep and wide spread inflltration 
 with the products of inflammation. The material found 
 bathing the infected surfaces will also depend upon the 
 same influence, being in mild cases merely a muco- 
 purulent fluid, in others purulent, or even bloody. The 
 normal red color of the endometrium is dee[)ened propor- 
 tionately, and may he almost livid: the mucous membrane 
 is thickened, softened, even pulpy at times, and easily torn 
 from its attachments. The interglandular spaces show an 
 increase of round cells, which, in extreme cases, are so 
 abundant as to give the whole surface the appearance of 
 
DISEASES OF THE I'TERUS— METRITIS. 221 
 
 granulation tissue. The epithelium is iutiltrated, and even 
 destroyed in certain places, and the cilia in general may 
 be said to have shared a like fate. The implication of the 
 muscular coat (metritis) is slight, except in some cases of 
 gonorrhceai infection. There is swelling of the muscular 
 fibres, increase of cell formation in the interspaces, and 
 infiltration with a serous or sero-purulent tiuid, by which 
 the uterus becomes more or less enlarged. Minute 
 extravasations of blood are apt to be found in spots, 
 particularly near the mucous membrane. 
 
 Sijiujdoiiis. In the simple form they may be compar- 
 atively insignificant. There will be a sense of fulness in 
 the pelvis, more or less pronounced, if there be arrest of 
 the menstrual tlow. accompanied by fret^uent micturition 
 and rectal tenesmus. In more severe cases the symptoms 
 are more decided. There will be dull deep seated pelvic 
 pain, backache, and aching down the thighs, increased by 
 motion or by the evacuation of the bladder and bowels. 
 Slight febrile reaction will also be present. In septic 
 cases a chill, more or less pronounced, ushers in the general 
 disturbance, accompanied by a rapid and decided rise of 
 temperature. Should the intlamnuition extend to the 
 peritoneal covering (perimetritis), the phenomena of local 
 peritonitis will be directly added; if it extend through the 
 Fallopian tubes the evidence of salpingitis will appear, 
 and from either of these general peritonitis may arise, or 
 other extreme symptoms indicative of general septic 
 absorption. 
 
 The chief physical signs are tenderness over the pubes, 
 and tenderness of the uterus, elicited by bimanual and 
 vaginal pressure. The cervix will be found patulous, 
 softer, larger, and redder than natural, particularly about 
 the external os, and exuding from it a tough, glairy, 
 opacpie secretion. When the uterine walls are afflicted, 
 particularly in septic iuHammation, the entire organ is 
 enlarged and softened, and then' will be noticed flowing 
 
222 MEDICAL AND SURGICAL GYXJICOLOGY. 
 
 from the os a thick, ichorous, bloody discharge, which 
 may have the odor of decomposition. 
 
 Fro(iiiosis. Ill the simple form life is rare'y en- 
 dangered, but in the septic forms it commonly is, either 
 through general peritonitis, or from general septic infec- 
 tion. The integrity of the organ is always tnidangered to 
 an extent proportionate to the severity of the inflammation; 
 slight, if any, in the milder forms. I»ut decidedly pro- 
 nounced in the graver ones. The dangers result in part 
 from the chronic changes in the uterus itself, and in part 
 from the implication of the adnexa. 
 
 JJidtinosis. In the non-pregnant uterus this lesion is 
 indicated by tenderness of the organ, and by discharge 
 from the cervix, taken in conjunction with the comparative 
 suddenness of an attack developed in connection with an 
 acute suppression of menstruation, with a prior vaginitis, 
 or with some such cause as an operation upon the cervix, 
 or the introduction of a sound. After a ortioii or labor 
 it is commonly indicated by a chill, followed by rise of 
 temperature, and temporary arrest of the lochia, with its 
 subsequent reappearance, and on reappearance often has 
 an odor of decomposition. The organ soon becomes 
 tender and subsequently loses its firmness. Such cases 
 may be confounded with typhoid or malarial fevers. If 
 malarial, quinine will control it absolutely ; if typhoid, 
 differences in the rise and fall of temperature will assist 
 in making a diagnosis. In all cases when in doubt, it is 
 wiser to assume the presence of septic infection. Local- 
 ized mastitis is another source of error, but a careful 
 examination of the breasts will readily correct that. 
 
 Tre^diucnt. From what has been said of the etiology 
 of the disease, it will be readily understood that the treat- 
 ment will vary according to the nature of the case. The 
 milder forms are best treated by rest in bed, purgations 
 by means of salines, by mild febrifuge treatment, and by 
 hot vaginal douches supplemented by hot fomentations, 
 
DISEASES OF THE ITERUS — METRITIS. 223 
 
 and counter irritation over the abdomen. If there is no 
 serious objection to physical examination, local depletion 
 may be accomplished by free scarification of the cervix, 
 followed by a warm vaginal douche. As soon as the more 
 acute symptoms have subsided, boro-glyceride tampons 
 may be i^laced against the cervix daily. When it arises 
 as a result of vaginitis, particularly that form met with in 
 gonorrhoeal infection, it will probably be necessary to 
 irrigate the uterine cavity with a solution of bichloride 
 (1 to 3000), dilating the cervix sufficiently for that 
 purpose, if it is not already patulous. In the septic forms 
 prompt and energetic measures are demanded. If the 
 result of negligence in failing to keep up proper aseptic 
 precautions during operations or examinations, the cavity 
 of the uterus should be freely irrigated with bichloride 
 solution and packed with iodoform gauze. Should a 
 wound exist, the lips had better be separated and kept 
 apart by strips of the same material. Should the case be 
 one of septic inflammation following abortion or labor, 
 radical surgical measures should be promptly applied. 
 The cavity of the uterus should be curetted, all debris 
 scraped away, and the uterus fully and tirmly packed with 
 gauze. The vagina must then be packed loosely, tirst 
 around the cervix and then down to the introitus. The 
 packing of the vagina should be removed at the end 
 of twenty four hours and warm stt^rile douches given. At 
 the end of forty eight hours the uterine packing may be 
 removed and, if no fever be present, the cavity of the 
 uterus need not again be entered, but if the temperature 
 is still elevated the cavity should be irrigated and fresh 
 gauze inserted. Even though the case appears desperate, 
 the cleansing and draining should be continued, for not 
 unfrequently it yields in the end. The gravest surgical 
 perplexity arises in connection with further operative 
 procedure. The removal of the infected uterus, either 
 through the vagina or by cu;liotomy. offers the surest 
 
224 MEDICAL AND SURGICAL GYNJICOLOGY. 
 
 relief, could the nhock of so grnve an operntiou be 
 controlled. Patients infected with a general sepsis rarely 
 withstand any grave abdominal, or even pelvic operation, 
 and although many successful cases have been reported, 
 it is still looked upon by many as justifiable only under 
 desperate conditions. 
 
 Stimulated by the success of serum therapy in 
 diphtheria and in a few other infectious diseases, effort 
 has recently been made to procure a serum that will be 
 antagonistic to streptococci and antidotal to the products of 
 their activity. This form of medication bids fair, thus far, 
 to be of great service in puerperal infection. Few reports 
 have yet been published regarding the use of the serum 
 antitoxine, but those that have been, serve to prove that in 
 cases of infection due to poisoning by the streptococcus 
 alone, the streptococci antitoxine, when used early, is a 
 curative agent of great value, but in mild cases of infection 
 in which, besides the streptococcus, the colon bacillus, the 
 bacillus fetidus, the staphylococcus, the bacillus pyocyaneus, 
 and other micro-organisms are found, this antitoxine has 
 little or no beneficial effects. 
 
 I" 
 
 si ENDoL'iiKvicrr: 
 
 Endocervicitis is recognized oy various synonyms, 
 such as cervical endometritis, cervicitis, cervical catarrh, 
 trachelitis, and erosion of the cervix. Inflammation 
 of the cervix exists independently of like lesions in 
 the body of the uterus, its position exposing it to 
 disease to a far greater extent than the deeper portions 
 of the organ, and as such requires separate consideration. 
 In acute processes, especially those derived from gonorrhcBa 
 and septic infection, the two parts of the organ are so often 
 involved together, that it seems unnecessary to consider 
 the lesions of the two separately. The appearance pre- 
 sented by the cervix in acute inflammation has already 
 been referred to. The mucous membrane of the canal is 
 
DISEASES OF THE I'TERrs— METRITIS. 225 
 
 swollen niid softened, nud its cavity filled with a viscid 
 muco-puruleiit secretion. The appearance presented by 
 the deeper portion of the cervix is also, in all respects, 
 similar to that met with in the body of the uterus. This 
 does not apply, however, to the chronic forms of the 
 disease; the inflammation being of a lower grade of 
 intensity, more strictly confines itself to the cervix, without 
 involving the d(H>per parts of the uterus. 
 
 Cdiiscs. Chronic endometritis may arise from a variety 
 of causes. Impoverishment of the blood from chlorosis or 
 some other form of malnutrition, producing lowered 
 vitality, strongly predisposes to the disease. Infection 
 from the vagina, such as from gonorrheeal or purulent 
 vaginitis, from the entrance of foreign bodies or septic 
 germs into the vagina, from examinations, operations, 
 coitus, masturbation, pessaries, and vaginal douches, may 
 infect the cervix directly. Laceration of the cervix is by 
 far the most frequent cause, and along with it may be 
 mentioned displacements of the uterus, opt^rations upon 
 the cervix, strong local treatment, and attempts at abortion. 
 P(itliol<Kjij. Endocervicitis is cliara(^terized by hyp«r- 
 femia, thickening of the cervical mucous membrane, and 
 hypersecretion of the glands. The mucous may be 
 unaltered, or it may be thicker than normal and excessive 
 in quantity. If the congestion is long continued, 
 exfoliation of the epithelium progresses faster than 
 its replacement by the development of new cells, so 
 that the membrane becomes covered with young epithe- 
 lium, giving it a reddish color (si niplc erosion). This 
 disturbance not only involves the mucous membrane 
 of the canal, but extends outward from the os, about 
 half the thickness of the walls of the cervix, giving 
 rise to the condition once described as ulceration. As the 
 process advances the mucous membrane becomes thick- 
 ened by proliferation of the areolar tissue, so that it 
 becomes too large for the surface which it covers, and is 
 
226 
 
 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 thus thrown into a multitude of minute folds, rugosities 
 or wrinkles. To this condition the name papillary erosion 
 has been given, as the small folds look like papillee. The 
 glandular pockets formed by these folds reach down to 
 and between some of the bundles of muscular fibres. 
 These pockets, as well as mouths of the glands, may 
 become closed and filled with secretion, forming cysts 
 of all sizes up to that of a pea, and give rise to that 
 condition called follicular erosion. When the hyper- 
 plasia is extensive, the thickened mucous m.nnbrane 
 
 Fig. 71. ^Erosion of the cervix, — a, ^.simple papillary erosion ; c, follicular slightly enlarged. 
 
 pverfills the cervical cavity, dilates the external os and 
 rolls out into view, giving the cervix the appearance as if 
 the vaginal portion were partly clothed with cylindrical 
 epithelium. This condition is called eversion or ectropion. 
 When the structures are more actively affected, or to a 
 greater depth, other changes are produced. The mucous 
 membrane throws out largo projecting folds which may or 
 
DISEASES OF THE TTERUS— METRITIS. 227 
 
 may not develop into mucous polypi or polypoid masses. 
 The occluded and cystic pockets and Nabothian glands may 
 project on the surface, and, if numerous, may occupy half 
 the thickness of the cervical walls, and produce a condition 
 known as cystic ((('(/('ucrotioH. As a result of these 
 changes all of the glandular structure may be finally 
 destroyed, and sclerosis, resembling senile atrophy, result. 
 
 Sijmphms. When mild, and of short duration, the 
 case may be free from all symptoms except a vaginal 
 discharge. This discharge, however, is in some degree 
 characteristic; it is not continuous, nor. in the absence of 
 vaginal implications, abundant. It is viscid and jelly-like, 
 and transparent, opaque, or yellowish according to the 
 amount of purulent admixture. In the presence of 
 cervical laceration, it is mixed with a un^re muco-purulcnt 
 discharge, and is at the same time more constant. In 
 deeper seated implication of the cervix there will be, in 
 addition to the discharge, dull lumbo-sacral pain, and, 
 perhaps, reflex nervous symptoms. On making a digital 
 examination, a softened ring is felt around the os, and, if 
 extensive cystic degeneration with eversion exists, the 
 cervix will be felt enlarged, soft, and elastic, with perhaps 
 isolated distended follicles, like buried shot under the 
 surface. 
 
 Laceration of the cervix, with extensive erosion, may 
 simulate carcinoma, but by examining under the micro- 
 scope a small strip removed by the knife, it can be readily 
 differentiated. A profuse serous and blood-stained 
 leucorrhoea is almost always characteristic of cervical 
 carcinoma, and so are the hard exuberant cauliflower 
 excrescences springing from the vaginal aspect of the 
 everted cervix. 
 
 Treatment. As the disease consists mostly of an 
 inflammatory degeneration of the cervical mucous mem- 
 brane, efforts should be directed to produce an alterative 
 influence uix)n that membrane; and as it is often associated 
 
228 MEDICAL AND SURGICAL GYNJICOLOOY. 
 
 with H depraved condition of the system, further efforts 
 must be made to iitt'ect favorably the general health. 
 Every function of the body should be regulated by 
 proper nu'unH, and vegetable tonics, mineral acids, and 
 preparations of iron administereil, and daily exercise and 
 good healthy nourishing food provided for. Particular 
 attention should be paid to the proper regulation of the 
 bowels, for which a ferrugineous tonic with a cathartic 
 may be prescribed, as in the following: — 
 
 R. Magiiewiif Sul|thati.M, oz. ii ; 
 Ferii Sulphatis, mn. xvi ; 
 Acid Sulphurio, Hil., dram i ; 
 Tinct. (ieiit. Co., oz. i ; 
 Elixir Siniplici.s, ad., oz. xvi. M. 
 
 Sip. — Two tablespoonsful in half a tumbler of ice water each morning. 
 
 R. Hodii' et I'otass. Tart., oz. ii ; 
 V^ini ferri amari, U.S.I), oz. ii ; 
 Afid Tartaric, dramis iii ; 
 Eli.xir Simplicis, oz. iv ; 
 A<iii!e ad., oz. xvi. M. 
 
 Sig. — Two tablesiKJOMsfuI in half a tumbler of water each morning on 
 rising. 
 
 Locally the source of irritation must be remove'' and 
 the ett'ects counteracted by mild antis(^ptic and astringent 
 applications. Endometritis and vaginitis, if present, 
 should be treated, and uterine displacements corrected. 
 Of local applications, the most important is the vaginal 
 douche. The water may contain permanganate of potash 
 (1 to ;}OUU). carbolic acid (1 to 100), or bichloride (1 to 
 5000), when for antiseptic purposes; and if required for 
 an astringent effect, sulphate of zinc, three grains to the 
 ounce, sulphate of copper, two grains to the ounce, or 
 acetate of lead, five grains to the ounce. Vaginal tam- 
 pons, saturated with boro-glyceride, or glycerite of tannin, 
 or a ten per cent, solution of ichthyol, may be introduced 
 by the patient every night, and removed the next morning 
 before taking the douche. 
 
 Local applications, such as a ten per cent, solution of 
 sulphate of copper, or crude pyroligneous acid, may be 
 
DisKAsiis OF Tin: iTuin's mktkitis. 229 
 
 made tliroiij^h a Hpcculum. twice r tl>r(H> times weekly. 
 In Home eaw^H the applic-ntioii. once in a wiu'k or ten (lays, 
 of strong ('arlM)lie acid, or tincture of iodine, or of the two 
 mixed in ecjual parts, seems serviceabh*. follow(>d at once 
 by the api)lication of a horo-Kly('cri(h' tampon. In all 
 cases the os should be w«^ll dilated, the mucous wiiu'd 
 away, and the application made frei^ly to the tMitire cervical 
 cavity and to the vaj^inal portion, by means of an api)li- 
 cator, or by for(H«[)s wrapju'd with cotton. When the 
 cervix is much indurat(*d and studd(^d with retention cysts, 
 Kcaritication is very useful. It acts by depletion and 
 allows the escape of tl)e inspissated mucous. The punc- 
 ture should be permitted to bleed a little, but if the 
 hemorrhage is too free it may be checked by absorbent 
 cotton Hrmly pressed against the cervix. Subseiiuently 
 tincture of iodine, or carbolic acid, should be applied, and 
 a small boro-glyceride or ichthyol tampon placed under 
 the cervix to maintain the antiseptic and alterative 
 acoion. 
 
 In cystic degeneration, the cysts must be laid open, and 
 carbolic acid or tincture of iodine applied. In very 
 chronic cases, where there is extensive degeneration of the 
 mucous membrane, it has been recommended to destroy it 
 by means of strong caustics or escharotics. but their use 
 is dangerous, it being impossible at times to limit their 
 action, and. besides, they are likely to [jroduce cicatricial 
 contraction. When glandular tissue is to be destroyed, 
 the most efficient way of doing so is by excision of the 
 mucous membrane, after the manner recommended by 
 Schroeder. 
 
 CHRONIC" CORPOREAL ENDOMETRITIS. 
 
 Like the cervix, the body of the uterus is liable to 
 chronic inflammation of its lining mucous membrane. 
 
 Causes. It may follow at once upon an attack of 
 acute endometritis, or metritis; or it may be brought about 
 by causes which delay or disturb involution after abortion 
 
Wiiil 
 
 l(;f 
 1/ 1 
 
 ^v^inuy wt.,t;:;,';;l,,r':;;rf ''" °"™ -<-«• 
 
 "vantm, „„,| „„„,, j,;^,,. "''''"'''' «'™™i« o( el,e cervix 
 '- -"ori,,,, „„,„„,;,• „'^.„^:''';'""»i in.,.rf„r,.„co wm,' 
 
 •x'lii'vo,! to bo pr«l,,,J„ '^"'™"" »"'! <l.-bilitv arc. 
 
 "f 'I- -™lo.m..ri„ ™r" """'' "■"""'. ""'I '.yi-rpta 
 J (ithohxni To f 1, , , 
 
 ■ '-woll™ „;„, ,„f, "" ""kec ..,e tho muoo„« „™br„„e 
 "'tl. Lore „„d „„.„, I J,,"'"; " ^emblos cjuinco jolly 
 
 muscular coat participates i,^ ,7 " "* """'' """ ">e 
 
 projections „„„ depr"^ „, J"'^'"'"'' P"'-"'inK alternate 
 go«.t.e8„„yb,„./'« These projections or fu„. 
 or they „„y b, veritable poly"" ""'?"'' "'o^'"""! form. 
 In other cases small cysts'T 1^7'''' ™ P""»"o"l»ted. 
 bodies met with in the ™'""'''"« »mewl,„t similar 
 
 "rophyofthemuco mlh:™!- "" f™^"'' ^•''«" 
 « smooth and glfetenin^.""";, ''",?"""'• "-surface 
 "troph.c changes, is thin am '""''" '"•'' oxtonsive 
 
 MicroscoDienI „ »»'' tr»"«P»rent. 
 
 three forms l^^L::Z^t """"™'"'- Presents i„ 
 '" o- "nd the s„me';X: T'"''' "' "" "■»""•«" 
 
 Jn the infcrsfifi'n/ f i 
 
 transformed into cicatr IT , '"'"Klandular tissue is 
 «h.nds, causing thet™ "r; iTn?''''"'' """"'"^^ "- 
 obLteration. I„ other'^„ "i thev"""""""^ """P'* 
 
 P'aces they are converted into 
 
DISKASIiS <)!' THK UTERI'S - MKTUITIS. 231 
 
 cysts, in number proporti()iiat(> to the doj^rrnof connective 
 tissue development. In extreme cases, of lon^ durntion, 
 the inu(H)us m(>mV)rane becomes atroi)liied. and is converted 
 into n thin hiyer of s(^h>rosed connective tissue. Embedded 
 in this sch^rotii! tissue, lien- and th(<re are cyst cavities, 
 the remains of constric^ti^l and (h'^i'iierated glands. 
 
 Thi^re are two forms of th(^ j/hnidnhn' varii^ty. one in 
 whicli the glands are incr(>ased in their dimensions 
 {hjipct'ivophic): and another in whi(Oi there is actual 
 increase in the ({uantity of gland tissue (hijitcrpldstir). 
 In the former, the utricular glands no longer appear as a 
 series of straight tubes, but are twisted, elongated and 
 arranged spirally. In the second form there is not only 
 increase in the number of the glands, but they are dis- 
 torted, and here and there present lateral prolongations or 
 diverticulre. 
 
 Chronic poli/poi'tl endometritis is a combinn*'on of the 
 interstitial and glandular varieties, with marked cystic 
 formation, together with great increase of the vessels, both 
 in number and in dimensions, and an increase of the 
 interglandular structure. In some cases the whole 
 mucous membrane is thickened, in others only portions, 
 while in others the glands are chiefly affected and project 
 as polypoid masses. The great increase in vascularity 
 accounts for the clinjcal behaviour of this variety, menor- 
 rhagia being the st. "iing symptomatic feature. In con- 
 nection with this la.st form of endometri'Js. there is a 
 variety resulting from the retention of portions of the 
 decidua. after abortion chiefly, but occasionally after labor 
 at term, cvdowfirififi deciihuilis. The retained tissue 
 presents itself as projectionr. from the general surface of 
 the mucous membrane, and is soft and easily detached. 
 Microscopically, it is diff'erentiated by the presence of 
 degenerated decidual tissue surrounded by a mass of 
 small cells. Clinically it presents symptoms of the 
 polypoid form by the profuse menstrual flow. 
 
232 MEDICAL AND SURGICAL GYN.13COLOGY. 
 
 Symptoms. The Hymptoms of (nidometritis vary to a 
 great extent, according to whether the case be a severe one 
 or not. They may scarcely attract attention, or they may 
 be so pronounced as to render life a burden. Mcnovrhdf/id 
 is by far tlie most common symptom. The flow may be 
 profuse and clotted, persisting at times longer than 
 normal, and at others contini:i'\tr during the larger part of 
 the intermenstrual i^eriod. particularly in the fungous or 
 Ijolypoid form. 
 
 LoucnrrlKrd is nearly always present between the 
 periods, although in old cases it may be so sliglit as not to 
 attract the patient's attention; after sclerosis of the 
 mucous membrane has resulted it may be absent altogether. 
 The discharge consists of a thin clear mucous, or muco-pus. 
 As it appears at the vulva it is rnilky white, creamy, or 
 greenish in color, owing to its having mingled with 
 cervical and vaginal discharges. When mixed with 
 blood it acquires a pink, brown, or smoky tint. 
 
 Pain of some kind is rarely absent. Lumbo-sacral 
 pain is a prominent feature, and it may radiate down the 
 thighs. Dull, persistent, deep seated pelvic pain is also 
 present, extending i^erhaps to the perineum. If the 
 organ is enlarged and anteverted there will be frequent 
 micturition and vesical distress; if retroverted there will 
 be mechanical constipation, with pain along the sciatic 
 nerves. Unusual or prolonged exercise, especially jolting 
 over roiigh surfaces, increases the pain. To the local 
 discomforts, neuralgic pains may be added, such as 
 occipital, intercostal, lumbo-abdominal. and facial neural- 
 gias; coccygodynia. gastralgia. meteorism. and similar 
 reflex symptoms may also be prestMit. 
 
 Sfcnlifi/ is a common accompaniment, owing to the 
 several obstacles to impregnation, and to proper decidual 
 growth. Sometimes the ovum does not reach the uterus, 
 or it may be destroyed by the secretion, or by forming 
 no attachment to the endometrium. 
 
 li Li 
 
DISEASES OP THE UTERUS— METRITIS. 233 
 
 Phi/sical sifpis. Palpation shows nothinj^ but a 
 symmetrical enlargement of the utjrus. Generally it is 
 tender on pressure, particularly when the cervix is touched. 
 In th'3 absence of complicating diseases of the adnexn, of 
 the utero-sacral lig' .lents, or of the peritoneul surround- 
 ings, the uterus i& .reely movable. The introduction of 
 the uterin"^ sound is ordinarily, though not invariably, 
 attended by pain, and in most cases a sensitive spot is met 
 with at the internal os. The canal may measure from 
 three to four inches in length, but the sound conveys 
 little information as to the state of the endometrium, unless 
 it be by the induction of bleeding in the decidual or other 
 hemorrhagic forms. 
 
 Didf/nosis. Pregnancy has been mentioned as a con- 
 dition with which the lesion may be confounded, but a 
 proper examination and consideration of the signs and 
 symptoms will readily determine which condition is 
 present. It may be mistaken for commencing fibroid 
 disease. If tlie disease be interstitial, and more particu- 
 larly if it be subperitoneal, conjoined vaginal and rectal 
 examination will reveal inequalities on the outer surface. 
 If the growth be wholly submucous, it may be detected by 
 the introduction of the sound. The hemorrhagic: form 
 may be confounded with abortion, but the early history 
 and a careful examination of the discharges will suffice for 
 differentiation. The diagnosis of certain forms of corporeal 
 and cervical inflammatory lesions from carcinoma is a 
 matter of pressing urgency, for, to be of any service, 
 diagnosis must be made early. Here the free use of the 
 sharp curette and a careful microscopic examination of 
 the scrapings will assist materially in clearing up the 
 difficulty, and should never be omitted in doubtful cases. 
 
 Pro(j)i(>sis is usually favorable as far as life is concerned. 
 Taken early, all forms yield readily, but after extensive 
 changes have taken place permanent cure is uncertain. 
 Of all forms, polypoid is the most obstinate, and it also is 
 
284 MEDICAL AND SURGICAL GYN^C()Lf)GY. 
 
 tho form which appears to tend most frequently to 
 carcinomatous degeneration. Every form tends towards 
 the induction of intlammation of the adnexa and 
 peritoneum. 
 
 Trcahneid. Cases witli profuse menorrhagia, unac- 
 companied by tumors or diseases in the adnexa, pelvic 
 peritoneum, or connective tissue, but with considerable 
 thickening of tho mucous membrane; fungous endome- 
 tritis, and in general all cases that have resisted long 
 continued local treatment, should be submitted to thorough 
 intra-uterine curettage. After completing the operation, 
 it may be considered advisable to touch the surface over 
 with strong carbolic acid, or tincture of iodine, or iodized 
 phenol, and to pack the cavity lightly with strips of iodoform 
 gauze. Subsequently the treatment should be along the 
 lines already enunciated in conjunction with the treatment 
 of acute metritis. Subsequently, an effort must be made 
 to keep up the free drainage through the cervix already 
 established, which maj'^ be done by occasionally passing a 
 dilator and introducing a few strips of gauze into the 
 cervical canal. Boro-glyceride or ichthyol tampons may 
 be inserted by the pAtient once a day, and allowed to 
 remain for twelve hours. After their removal, the vagina 
 shovtld be douched with hot water, and again before rein- 
 sertion of the tami^on. If the disease does not seem to 
 yield, thorou'^h curetting had better be repeated, and in 
 the intervals, when dilating the os, the endometrium may 
 be lightly touched over with a twenty five per cent, solution 
 of ichthyol, or with stronger preparations, if thought 
 advisable, such as tincture of iodine, carbolic acid, or a 
 twenty five per cent, solution of chloride of zinc. Success 
 in treatment will largely di^pend upon a removal of the 
 conditions which cause and perpetuate the disease. 
 Retroversion, retroflexion, and prolapse of the uterus may 
 need correction. Inflammation of the cervix, ovaries, or 
 of the tissues surrounding the uterus should be treated. 
 
DISEASES OF THE UTEKUS—METRITIS. 235 
 
 Special cnre slioukl bo tnken at each monstrual poriod; a 
 few (lays spe^iit in binl will often do much to check monor- 
 rhagia or dysmenorrhcea, should one or the other bo 
 present. Throughout the whole intermenstrual jjoriod 
 the mode of living should be one of extreme (luietudo, 
 both mental and physical. 
 
 CHRONIC METRITIS. 
 
 To this condition the synonyms chronic parenchy- 
 matous metritis; (ircolar luipcrpldsid; and suhinrolntion 
 and sclerosis have been applied. 
 
 Etiologi/. Chronic metritis may result from three 
 entirely different pathological states: — First, from inter- 
 ference, from any cause, with retrograde metamorphosis 
 of the puerperal uterus after abortion or labor at term, 
 such as puerperal metritis, retained secundines, septic 
 innoculation, laceration of the cervix, over-exertion after 
 confinement, or suppression of milk. Acute diseases 
 occurring during the period of involution have a similar 
 effect. Second, from congestion long kept up by mechan- 
 ical causes, such as displacements, pelvic tumors, and 
 chronic diseases of the pelvic or abdominal viscera; or from 
 congestion indirectly produced by sedentary habits com- 
 bined with constipation, by laborious occupations kept 
 up during the menstrual period, or by long standing 
 cardiac disease. Thirdly, from a formative irritation, or 
 a state of hypernutrition excited by endometritis. 
 
 Pdtholoiii/. After joarturition the muscular fibres 
 undergo fatty degeneration, by which the organ rapidly 
 dimiidshes in size, so that, at the end of the eighth week, the 
 uterus will have returned to its normal state. Untoward 
 influences may retard or check this process, and the uterus 
 will accordingly remain large, fiabby, and softer than 
 natural. As a result there is hypont'mia, serous infiltra- 
 tion, and a large increase of embrj'^onic elements. Later 
 an increase of adult connective tissue between the bundles 
 
236 MEDICAL AND SURGICAL GYNiECOLOGY. 
 
 of muscular fibres arises, wliich in time compresses the 
 blood vessels, and leads to uterine aujemia with atrophy 
 of the muscular tissues. The uterus becomes harder than 
 natural, and remains for a long time enlarged, but in time 
 begins to diminish in size as a result of contraction of the 
 connective tissue, and in a few cases becomes smaller 
 than normal. 
 
 During each menstrual period the uterus, being to 
 some extent an erectile organ, is enlarged and distended 
 with blood. If from some cause it does not return to its 
 normal intermenstrual quiescent state, chronic congestion 
 with hypergenesis of its tissues will follow, and, as a result, 
 the organ will increase in size month after month, until 
 the circulation becomes finally constricted, and in a 
 hardened state the uterus will remain enlarged until 
 after the menopause. 
 
 Displacements of the uterus at first result in passive 
 congestion. Fibroids keep up constant nervous irritation 
 that induces hyperemia. Cardiac disease and abdominal 
 tumors interfere with the return of blood through the 
 vena cava and jjroduce blood stasis, any of which, when 
 continued for a length of time, will induce hypergenesis 
 of connective tissue in the uterine walls. 
 
 Course and termination. The length of time which 
 the condition may last is very uncertain. After the 
 connective tissue has once become thoroughly affected it 
 rarely returns to its original condition. The extent of the 
 enlargement of the cervix, the result of areolar hyperplasia, 
 is sometimes very great, equaling in size, at times, a small 
 orange. 
 
 Sifniptoms. After labor or abortion, the first symi^tom 
 may be a return of the discharge soon after the patient 
 gets up, or the menses may return abundantly in three or 
 four months, while the child is still nursing, or there may 
 be complete menorrhagia. It is not to be forgotten, 
 though, that some women menstruate regularly throughout 
 
DISEASES OP THE UTERUS — METRITIS. 237 
 
 the whole period of lactation. In all cases, after the 
 disease has been well established, there will be a dull 
 dragging pain through the pelvis, much increased by 
 locomotion; pain on defecation or coition; and painful 
 menstruation, commencing several days before the flow 
 appears and lasting during the whole period. There is 
 often noticed pain in the inammce before and during men- 
 struation; darkening of the areolre of the breasts, if 
 lactation is not present; nervous disturbances; and rectal 
 and vesical tenesmus. As felt bimanually the uterus, in 
 the earlier stage of subinvolution, is enlarged, but more in 
 its long diameter than in its transverse; is slightly softened, 
 somewhat tender, and probably situated low down in the 
 pelvis. The cervix is more or less enlarged and softer 
 than normal. The os is purplish in color, and firm, unless 
 cervical endometritis is present. In cases of long standing, 
 the uterine tenderness diminishes, the walls become hard, 
 the cervix paler in color, and, as sclerosis supervenes, the 
 body becomes somewhat flattened. It might be mistaken 
 for pregnancy in the early stages, but the early symptoms 
 of that condition are entirely wanting. 
 
 Treatincnt. The sooner treatment is adopted the 
 better, before the stage of induration is accomplished. 
 Cases discovered a few weeks after delivery or abortion 
 should be again put to bed and perfect quietude insisted 
 upon. Any causes which may have been etiological factors, 
 such as retroversion or retained secundines, should be 
 removed. Hot vaginal douches three times a day are 
 decidedly beneficial. Internally, fluid extract of ergot 
 given alone, in half dram doses, three times a day, or 
 combined with fluid extract of hydrastis, in ten drop doses, 
 will have a decided elt'ect in promoting involution. Two 
 or three drams of blood may be removed from the cervix 
 by scarification, three times a week, and a tampon saturated 
 with boro-glyceride placed against the cervix and allowed 
 to remain for twelve hours. 
 
238 
 
 MEDICAL AND SURGICAL GYNiECOLOGY. 
 
 In the enrly stages of menstrual subinvolution, uterine 
 displncement, or other onuses which keep up the menstrual 
 congestion, should be corrected. During each menstrual 
 period perfect quiet, with rest in bed, should be enjoined. 
 During the stage of infiltration both forms yieUl readily 
 to treatment. The appropriate measures to be adopted 
 for such are cleansing the uterine cavity, removing 
 exuberant and diseased tissue^ and 
 checking its reproduction by airect 
 applications, aided by enforced deple- 
 tion and efficient draJnage — the methods 
 for which are identicf 1 with that already 
 enunciated in conjunction with the 
 t 1 / / ' / treatment of endometritis. The appli- 
 cation, twice a week, of fifty to sixty 
 milliamperes of the galvanic current, 
 with the negative poh^ intra-uterine, 
 
 Fig. 72 — Amputation of the cervix with ilouhle flaps. W, sectional view, showing lines of 
 incision for formation of ttapa and method of suture ; B, front view of cervix, operation 
 complete. 
 
 will soften the uterus and promote absorption. Pelvic 
 massage will also stimulate the circulation and promote 
 absorption. 
 
 Operative interference is often of much advantage for 
 the purpose of removing redundant tissue, and to alter 
 the circulation and the nutrition of the uterus. If the 
 cervix is lacerated, trachelorrhaphy should be performed. 
 Where there is decided circumferential enlargement of 
 the cervix and the canal dilated, a wedge-shaped piece 
 may bo cut out of one or both sides, and the surfaces 
 
DISEASES OF THE UTERUS— ACQUIRED ATRESIA. 239 
 
 brought togotlior ns in trncholorrlmpliy. When this 
 tnilnrgoment takes the shnpo of an elongation as well as 
 thickening, amputation should be i)erformed. 
 
 Schfoedei'^s met hod for ampntdtion of the cervix. By 
 means of lateral incisions convert the cervix into anterior 
 and posterior lips; next remove the anterior lip by two 
 transverse incisions — one on the vaginal and the other on 
 the cervical side— by cutting upwards towards the supra- 
 vaginal portion of the cervix until the incisions meet each 
 other high up in the cervical tissue. The two flaps thus 
 formed are stitched together. A similar operation is next 
 performed on the posterior lip. 
 
 CHAPTER XXII. 
 
 DISEASES OF THE UTERUS CONTINUED. 
 ACQUIRED ATRESIA. STENOSIS. HYPERTROPHY. 
 
 Besides the result of a congenital defect, the uterus 
 may become closed later in life, producing a condition 
 know as (lequired (dresid. This condition may bo brought 
 about by adhesions forming after child-birth or abortion, 
 or by cauterization with strong caustics or the actual 
 cautery. Sometimes it is simply due to old age, especially 
 when the patient suffers from prolapse. As a result of 
 acquired closure, there may be hematometra or pyometra; 
 the treatment for which consists in overcoming the atresia 
 by puncture, and subsequent evacuation of tlie contents of 
 the uterus, after the manner previously described. 
 
 Stenosis of the cervix is an abnormal narrowing 
 occurring in some part of the cervical canal. It is most 
 common at the exti^rnal os, wlu^re the opening may be 
 found so small as not to admit the finest uterine sound 
 (pin-hole os). Less frequently it is found at the internal 
 OS, while sometimes the whole cervical canal is involved 
 
240 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 in the stonosis. In acquired stenosis the prominent 
 symptom is obstructive dysmenorrhcxia, produced by the 
 difficulty whicli the menstrual flow meets with in passing 
 through the cervix. If not relieved it may give rise to 
 chronic endometritis and chronic metritis. 
 
 Ti'catment. At one time all sorts of metrotomes and 
 scissors, for the purpose of overcoming the obstruction, 
 were in use, but these have now been abandoned as 
 unnecessary. With tht^ patient under an anjesthetic, the 
 cervical canal is entered by means of a fine dilator (Hanks') 
 and the process of dilatation proceeded with. When 
 sufficiently dilated, a glass or hard rubber stem pessary is 
 inserted into the cervical canal and retained there for 
 two or three months. 
 
 Hypertrophy of the uterus. An increased size of the 
 uterus is commonly due to subinvolution or chronic 
 metritis, but it may be also due to simple hypertrophy, 
 independent of inflammatory action. General hypertrophy 
 is a very exceptional condition, the cervix being the part 
 usually affected. 
 
 Hypertrophy of the oervix is divided into infra-vaginal 
 and supra-vaginal. 
 
 I)}fr(t-r:<((ji)i(d luj'pcrtropliii consists in an increase in 
 the size of the vaginal portion of the uterus. If congenital, 
 the enlargement takes place chiefly or exclusively from 
 above downwards, resulting in an elongated cervix. If 
 acquired, the cervix is not only elongated, but thickened, 
 and is frequently thicker near the end than at the base. 
 
 Treatment. Slight degrees of elongation may be suc- 
 cessfully treated by dilatation, which enlarges the os and 
 shortens the canal. If it is more extensive, amputation of 
 the cervix may be called for. 
 
 Snpra-Vdfiindl lii/pertrophy consists in the increase, 
 especially elongation, of that portion of the cervix situated 
 above the utero-vaginal junction. This condition is due 
 to prolapse of the vagina, while the body of the uterus 
 
DISEASES OP THE UTERUS— DISPLACEMENTS. 241 
 
 romnins in plnco, tho prolapsod vn^iiin pulling down tho 
 oorvix nnd thus olongnting it. The symptoms nri'^ thoso 
 of prolfqjso of tho vngiim, with perhaps tho npponranco of 
 ft hyportrophiod corvix at tho vulva. 
 
 Trratmcnt. In the lesser degrees the uterus may be 
 pushed up, and the cervix supported by a cup-shaped 
 pessary attached to an abdominal .belt. In more serious 
 conditions recourse must be had to operation. Simple 
 amputation of the cervix may be sufficient; if not, recourse 
 may be had to supra-vaginal amputation of the cervix, an 
 operation is reality similar to amputation of the cervix 
 already described, only the incisions are made higher up. 
 
 Schroedcr^s mcihod for siqird-raf/iiuil (imputation. 
 An incision is made through the mucous membrane at the 
 utero-vaginal junction, and the cervix separated carefully 
 all around, for some distance up. A ligature is passed on 
 each side, around the uterine arteries, to control them, as 
 in the operation for vaginal hysterectomy. The anterior 
 vaginal wall is next cut through, and the anterior vaginal 
 mucous membrane stitched to the mucous membrane of 
 the cervical canal. The posterior wall is next severed 
 and the posterior vaginal mucous membrane stitched in a 
 similar way, thus uniting the mucous membrane of the 
 cervical canal all around to the vaginal wall. 
 
 Hc<j(ir''s operation differs from Schroeder's in that tho 
 excised piece forms a cone, tho length of which may bo an 
 inch to an inch and a half above the utero-vaginal junction. 
 
 CHAPTP]R XXIII. 
 
 DISEASES OF THE UTERUS CONTINUED. 
 DISPLACEMENTS. 
 
 Even in perfectly normal conditions the uterus is 
 liable to vary greatly in its relations to the pelvic cavity 
 in which it lies. These relations are modified by its own 
 
242 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 functioiml nctivitieH, as woll ns by tlu^ distontioTi niul 
 ovacuation of the adjacent viscera. With this wido range 
 of physiological mobility, it is kept in place by the 
 surrounding connective tissue, by folds of peritoneum as 
 it is reflected over its walls, and by special ligaments, all 
 of which have alreatly been described in an earlier 
 chapter. When it fails to retain its eciuilibrium, either by 
 excessive movement beyond its normal rangt*, or by losing 
 the power to recover its normal relations, its displacement 
 becomes pathological. 
 
 Cldstiijicdfioii. Five kinds of displacements are recog- 
 nized: — Version, or displacement involving a change in 
 the axis of the uterus. Flexion, or deformity involving an 
 increase or alteration in the normal slight anterior curve 
 of the uterine axis. Prolapse, or displacement of the 
 uterus in the axis of the pelvic outlet. Torsion, or twisting 
 of the uterus on its long axis. Inversion, or sinking of 
 the upper part of the uterus into its own cavity, or com- 
 pletely down through its canal, into tlie vagina. 
 
 ANTEVERSION. 
 
 The uterus is said to be anteverted when its position 
 is so changed from the normal one that the fundus 
 apiJroaches the symphysis pubis, and the cervix points 
 towards the upper portion of the sacrum. The cause of 
 anteversion of the iiterus is usually an increased weight of 
 the organ, produced by subinvolution, hypertrophy, 
 fibroid tumors of the anterior wall — conditions generally 
 accompanied by relaxation of the ligaments and supports, 
 which permit the anteverted uterus to sink down into the 
 cavity of the pelvis. 
 
 Symptoms. From pressure of the uterus upon the 
 bladder, there will be frequent desire to urinate. In the 
 erect position, there will be a bearing down sensation, and 
 on attempting to walk, an uncomfortable dragging feeling. 
 By digital examination, the body and fundus of the uterus 
 
DISEASES OF THE I'TEKUS- DISPLACEMENTS. 
 
 248 
 
 9 
 
 I 
 
 will bo found close to the sytni)hyHiH pubiB, touching it, or 
 (^ven bolow it, nnd tlui cervix pointinjjf towards the middle 
 or upper portion of the sncrnl excnvntiou. 
 
 Trcatnioif. As in mnny cnses the displncements 
 depend upon subinvolution or iiyperphisin, the first 
 attempts at treatment must be for the restoration of the 
 organ to its normal size, after which it will likely return 
 to its normal position without further interference. It 
 would be useless to attempt the introduction of any 
 instrument for the mechanical support of the organ, 
 without such previous treatment, and, as the symptoms 
 are genc^rally relieved after the 
 condition which produced them /'' 
 
 has been overcome, the large 
 number of pessaries once found in 
 the instrument shops have now 
 disappeared, as being wholly un- 
 necessary in the treatment of this 
 deformity. There is one pessary, 
 Grehrung's, which is still held in 
 favor for anteversion. It is double- 
 horseshoe shaped, and is inserted 
 bj' slipping it sideways into the 
 vagina, and then turned so that 
 both bars rest between the sym- 
 physis pubis and the anterior aspect of the uterus. 
 Operative measures of various kinds, such as fixation of 
 the cervix to thvi anter'or wall of the vagina, and shorten- 
 ing of the anterior vaginal wall, have been proposed and 
 carried out, but they have not been received with much 
 favor. 
 
 ANTEFLEXION. 
 
 Anteflexion is an exaggeration of the normal anterior 
 curve of the uterus. The body of the uterus may be bent 
 down upon the cervix, or the cervix may be bent upwards 
 towards the body. 
 
 Fk;. 73. -CJehruiig's pessary. 
 
244 MEDICAL AND SUROICAL OYN,EC()L()GY. 
 
 (htU)iCH. (■(ni<i<'nif((l. In oarly lif(5 tlio normal aiito- 
 floxioii of tli(^ utcTUH i8 very pronounced. Ah puberty 
 approaohoH, tho body of tho organ dc^vt'lops very decidedly, 
 and tends to become more erect. In Homo, however, as 
 puberty approacheH, such erection of the organ fails to 
 occur, and antefioxion is tlu^ result Failure of the genital 
 organs to dtwelop synimetrically, or as fast as the pelvis 
 <l'.'veiops, favors the formation of autetlexion. The short 
 sacro-uterine ligaments draw the upper portion of the 
 cervix backward, while the short, ill-developed vagina 
 holds the lower end of the cervix forward, as in tho 
 normal condition in young children. The cervix is thus 
 bent forward into the vaginal axis and, accordingly, is 
 apt to be elongated, conical, and with stenosis of the os, 
 while the ill-developed fundus is forced over the bladder 
 by downward pressure. 
 
 Changes in the uterus. Inflammatory changes in the 
 uterine walls, or their relaxation, or atrophy of tho tissues 
 at the internal os, favor exaggerations of the normal 
 anteflexion. 
 
 ClKDKjes in the liyaments. Shortening of the sacro- 
 uterine ligaments may take place from contraction follow- 
 ing parametritis posterior, or from peritoneal inflammation 
 about them. When such occurs the ligaments drag the 
 upper i)art of the cervix toward the hollow of the sacrum, 
 while the body of tho uterus becomes bent in an exagger- 
 ated degree by the superincumbent structures. 
 
 Sifjnijicance. In unmarried and sterile women ante- 
 flexion is by far the most common form of displacement. 
 The views held concerning this condition have of late 
 been changed materially, and the exaggerated ideas once 
 held of the cliiiical importance of anteflexion have been 
 almost entirely abandoned. Recent investigations have 
 shown that, in minor degrees, antofloxions are practically 
 of no importance, neither causing pain nor preventing 
 conception; and when of a more marked character they 
 
DISEASES OP THE UTEUU8 — DISPLACEMENTS. 215 
 
 produce only two possible' hnd results, imniely, dysmeiior- 
 rlnvn mid sti^rility. 
 
 Si/inpfoniH. As 1ms been explaiiu'd, tlit* symptoms nro 
 not very marked. Aside f n m dysmenorrluim and sterility, 
 ftii uiioomi)li(;nted fiexioti produces no symptoms. CVr- 
 tnin complications mny. however, be present, which, 
 even in tlie minor degrees of tlexion, may produce 
 symptoms such as chronic catarrh of the uterine mucous 
 membrane and spasmodic contraction of the circular 
 fibres at the internal os. The first may produce congestive 
 dysmeuorrhom; the second the obstructive or neuralgic 
 variety. Digital examination will tind the cervix well 
 back in the pelvis, and pointing forward almost in the axis 
 of tlu^ vagina. Tlu^ angle of flexion can easily be felt, the 
 cervix lying under, and the body of the uterus over, the 
 finger. By bimanual and rectal examination, it is possible 
 to determine the condition of the ligaments and the extent 
 of adhesions, if any. The sound often gives material help 
 in determining the exact position of the fundus, and to 
 facilitate its introduction, it may have to be bent pretty 
 sharply towards the point. There is a condition known 
 as anteflexion with retroversion, in which, from child- 
 birth, debility, or other causes, the uterine ligaments have 
 become relaxed, and allow retroversion to take place after 
 flexion has become permanent. In such cases the ante- 
 flexed uterus falls into retroversion in Douglas' cul-de-sac. 
 
 Treatment. The minor degrees of anteflexion require 
 no treatment. Catarrh of the endometrium, engorgement 
 of the uterus, congestion of the ov ries and tubes, if 
 present, should be treated on accepted principles. Para- 
 metritis posterior, and adhesions from recent peritoneal 
 inflammation, are benefitted by vaginal tampons. To 
 overcome the two ijrominent symptoms, dysmenorrhcwa 
 and sterility, stenosis of the os nust be overcome, the 
 flexion straightened, and the canal kept open. This can 
 best be done by dilatation of the cervix, under an 
 
246 MEDICAL AND SURGICAL GYN/ECOLOGY. 
 
 nric'cstluitio, niul if no inflnmmntory condition exists to 
 contrnindicuti' it, by the HnbHixj^ucnt introduction of a 
 glass stem pessary, to be worn for two or thro(^ nonths. It 
 may be held in position for the first few days by a gauzt> 
 taniijon, and subsequently by a Thomas cup pessary. If, 
 from satisfactory reasons, it is deemed advisable to intro- 
 duce the glass stem, repeated dilatation with Hanks', 
 or other small dilators, may be employed at the home of 
 the patient. In old cases, with well pronounced endom- 
 etritis, accompanied by rigidity of the uterus and dys- 
 menorrluiea, thorough dilatation of th*? cervix, curettage 
 and cauterization of the endometrium should be first 
 performed. The use of pessaries of any kind whatever 
 have been abandoned, the best results b(ung obtained 
 from mechanical treatment. Should impregnation occur, 
 a complete cure may with certainty be promised. 
 
 RETROVERSION AND RETROFLEXION. 
 
 The uterus is said to be retroverted when the body 
 of the organ is turned backward. According to the degree 
 to which the tilting is carried, the os points downward, 
 or forward against the symphysis, and the fundus turns 
 upward, or backward towards the sarrura. Retroi'u .Tion 
 is that displacement in which the body of the uterus is 
 bent backward, the cervix remaining in its normal position. 
 As in most cases of retroflexion some degree of retro- 
 version is present, the os will change its direction also, 
 and in well marked cases, the fundus will be found lying 
 in the lowest part of Douglas" pouch, and the os looking 
 toward the lower margin of the symphysis. 
 
 Causes. When the utero-sacral ligaments are relaxed, 
 the cervix is liable to be carried too far forward, and the 
 fundus is then likely to fall backward. When the round 
 ligaments are relaxed and fail in their function of keepiirg 
 the fundus directed forward, retroversion is favored. 
 Along with changes in these ligaments, there is apt to be 
 
DISEASES OF THE ITERUS— DISPLACEMENTS. 
 
 247 
 
 rclnxntion of the broad ligaments, and of tho structures 
 whicli enter into the formation of the floor of the pelvis, 
 the result of over-distention, subinvolution, or laceration. 
 If the bladder and rectum are proialJS(^d to some extent, 
 as they are apt to be under such circumstances, the 
 subinvoluted uterus, having lost much of its support, 
 descends somewhat into the pelvis, and a backward tilting 
 of its bo( V is the 
 inevitable result. 
 Changes in the 
 uterus, causing in- 
 duration of the 
 uterine tissue, and 
 destruction of its 
 normal flexibility, 
 such as that pro- 
 duced by subinvo- 
 lution, chronic me- 
 tritis, and tumors in 
 the walls, render 
 that organ liable to 
 be affected by the 
 influences that press 
 the fundus back- 
 wards, and it will thus suffer retroversion. It may occur 
 as a result of a strain, or fall, or other jar to the body, 
 especially if the accident occurred at a time when the 
 fundus was tilted backward by a distended bladder, and, 
 remaining in that iiosition, is pressed into a persistent 
 state of retroversion or retroflexion by the superincumbent 
 pressure. Habitual over-distention of the bladder will 
 keep the fundus directed towards the promontory of the 
 sacrum, and a permanent retroversion will thus be 
 acquired. A permanent backward displacement is, in 
 some cases, the result of peritonitis leading to adhesions 
 that bind the posterior surfaces of the uterus to the 
 
 Fig. 74. — Anteflexion with -etroposition. 
 
248 MEDKJAL AND SURGICAL GYNECOLOGY. 
 
 rectum nnd to the posterior wall of the pelvis. Backward 
 displacements may arise from congenital defects, or from 
 subsequent want of symn'etrical development between the 
 pelvis and genital organs. Congenital shortening of the 
 sacro-uterine ligaments, combined with retarded develop- 
 ment of the vagina, will draw the cervix forward, and 
 hold the fundus backward. 
 
 Sijmpfoms. Of all the displacements, retroversion and 
 retroflexion are the most common. When the displace- 
 ment has persisted for some time, the patient will 
 complain of a bearing down or sinking sensation in the 
 pelvis during standing or walking; and pain in the lower 
 I)art of the sacrum and coccyx, perhaps extending down 
 the back of the thighs along the course of the sciatic 
 nerves. Sterility, leucorrhoea and profuse menstruation 
 are often prominent symptoms. If the ovaries are pro- 
 lapsed, the pain will be more acute. The function of the 
 rectum may be disturbed, preventing an easy escape of its 
 contents, or causing frequent desire for defecation, accom- 
 paaied by mucous dejections. Reflex symptoms are often 
 present, characterized by hemicrania, frontal and occipital 
 headache, intercostal neuralgia, gastralgia, nausea and 
 vomiting, or there may be a general depressed nervous 
 condition. The examining finger will find the body of 
 the uterus horizontal, or tijiped backward, more or less, 
 into the excavation of the sacrum, with the cervix pointing 
 upward, toward the anterior wall of the vagina, in retro- 
 version; or in the axis of the vagina, with an angle at the 
 junction of the cervix and body, in retroflexion. 
 
 Bimanual palpation will show the body absent from its 
 natural position, and the use of the probe will indicate the 
 direction of the uterine canal. If the ovaries and tubes 
 are prolapsed, they will be found lying on either side, or 
 immediately behind the body of the uterus. 
 
 TreatmoHt. The treatment consists in the restoration 
 of the displaced organ to its normal position, and its 
 
DISEASES OF THE UTERUS — DISPLACEMENTS. 249 
 
 rotontiou there. Elevation of the retro-displaced uterus 
 may be aeeoinplished by the fingers, posture, and instru- 
 ments. The usual method is to put the patient in Sims' 
 position, insert the index and middle fingers of the right 
 hand into the vagina, and press the body upward, nhvr 
 which the index fiugin* is passed in front of the cervix and 
 pushes that part backwards, while the middle finger 
 remains in tlu^ posterior pouch. If this method fails, 
 particularly wlu^n the case is one of impaction, the patient 
 may be put in the genu-pectoral position, and. after 
 admitting air into the vagina by means of a Sims' 
 speculum, efforts are made, by the aid of a depressor or 
 cotton on a holder introduced into the riictum, to dislodge 
 the fundus from the sacral excavation. If these manual 
 and postural methods fail, the reposition may be attempted, 
 with the patient in the dorsal or Sims" position, by means 
 of a large blunt sound or Sims' or Emmet's repositor. 
 The uterus having been replaced, it should at once be 
 retained in its normal position by a properly fitting 
 support, or. if considered inadvisable to use such, by 
 tampons, or gauze packing inserted behind the uterus. 
 It may not be possible to (completely restore the uterus at 
 the first attempt, in which case the attemi^ts are to be 
 repeated at suitable intervals, the advantage gained at 
 each attempt being kept up by the insertion of tampons. 
 Pessaries. There is mujh diversity of opinion on the 
 use of pessaries generally, but, notwithstanding the pro- 
 gress made in treatment of displacements through surgical 
 aid, pessaries seem to be, to some extent, a necessary evil. 
 As has already been stated, in anterior displacements 
 pessaries are but little used; and in prolapse, especially 
 when there is (h'scent of the vaginal walls, it has been 
 shown, when speaking of rectocele and cystocele, that they 
 cannot be well retained, and hence ari^ of little or no 
 benefit. In retrofiexion tlu'y are still found to be of much 
 UBe, but to obtain beneficial results, two indispensable 
 
250 
 
 MEDICAL AND SURGICAL GYN/ECOLOGY. 
 
 conditions miiHt bo observed:— First, that the uterus 
 sliould bi' returned to its norinfil position; second, tlint 
 the pessary should bo properly fitted, and should, without 
 injury or discomfort to tho wearer, retain the uterus in its 
 normal position. 
 
 Varieties. The cardinal principle upon which most 
 pessaries for retro-displacements are 
 constructed is that of leverage, first 
 introduced by Dr. Hodge. It acts on 
 the principle of the pushing down of a 
 short anterior lever, and the consociuent 
 Fig. 7s-Hodge pessary, tilting upward of a loiig postorior lever, 
 and all pessaries for rotro-displatiomonts, with few excep- 
 tions, are based on this idea. The instrument devised by 
 Hodge is of equal width at both extremities, and with two 
 curves. Albert Smith modified this form by narrowing 
 and pointing the lower extremity, in order to enable it to 
 rest upon the symphysis — an innovation which has proved 
 
 Fi<;. 76— Allien Smith 
 Pess.nry. 
 
 Fig. 77 — Thom.as' retroflexion 
 pessary. 
 
 a permanent one — and nearly all pessaries are constructed 
 after that plan. According to the length and width of tho 
 vagina, the depth and width of the postorior vaginal 
 pouch, the firmness or relaxation of the postorior vaginal 
 wall and ijorineum, the pessary will have to be broader, 
 longer, or more or less curved. If there is retroflexion, 
 with considerable relaxation of the posterior vaginal wall 
 and uterine ligaments, a pessary with a sharp postorior 
 curve will usually be required. For this form of displace- 
 ment Dr. Thomas has added a bulbous enlargement on 
 
DISEASES OF THE UTERUS— DISPLACEMENTS. 251 
 
 the posterior crossbar, wlioreby the body of the uterus is 
 prevented from tipping mid biuidiiig backwards. 
 
 C()iifr<i-{nilic(ifi(nis. All imrnovabhi, iioii-replaceabie 
 uterus is always an absolute contra-indication to the use 
 of a pessary, whethc^r the cause be recent or remote. So 
 also is the presence of fibroid or ovarian tumors. 
 
 Tm^crtion. The patient being placed on the back- 
 some prefer Sims' position — a suitable pessary is selected, 
 and smeared with some unguent. The anterior cross-bar 
 is taken between the index finger and thumb of the right 
 hand, and the pessary held vertically, while the index 
 finger of the left hand is made to draw back the perineum. 
 The pessary is now passed between the vulva, through the 
 introitus vagiiue, and, as it is about to impinge ; 'jon the 
 cervix, the index finger retaining th(^ perineum is passed 
 inward, and catching the posterior bar. draws it downward 
 and backward under the os. The right hand continues to 
 push the pessary onward, and at the same time rotates it 
 from the vertical to the horizontal position. 'The anterior 
 bar must then be depressed downward and backward to 
 settle the pessary in its place, and while so doing the left 
 finger should make sure tliat the cervix is in its proper 
 place. 
 
 A pessary properly fitted should produce neither pain 
 nor discomfort, but sometimes, after it has been worn for 
 a few months, abrasions are formed by pressure, and tlu>y 
 may even become imbedded -n the vaginal walls. In this 
 way urinary and rectal fistulje have been formed. After 
 introduction, it is well to allow the patient to walk about, 
 to make certain that it gives no discomfort, aftc^r which 
 she should be re-examined to ascertain that the pessary 
 remains in position. The patient should be advised to 
 take a tepid vaginal douche every day and to return from 
 time to tim(> for i-xamination. 
 
 When tlu^ fundus and body of the uterus are adherent 
 from inflammatory adhesions, or cicatricial contractions, 
 
252 MEI>1C!AL AND SURGICAL GYNAECOLOGY. 
 
 attempts to roplncci the ori^nn will usunlly fail, and an 
 effort must then be nmdv to softi^n and gradually detach 
 or stretch tluMU. This may be done by careful bimanual 
 and rectal rnaiiiijulation, by uterine massage, and by 
 vaginal pa(^king with tampons or gauze, with the patient 
 in the genu-pectoral position. 
 
 Opcrativr treatment. When a pessary fails to cure 
 the displacement, or when the uterus cannot be held in 
 place, an operation may be performed to accomplish this 
 purpose. 
 
 Extra-peritoneal shortening of the round ligaments. 
 Ale. r (UK lev'' s oiienitlon. This consists in making an 
 incision over the external inguinal ring on each side, 
 dissecting out, picking up, and drawing out the round 
 ligaments, until the fundus points towards tlie anterior 
 abdominal wall. Tlie ligaments are then ma(h^ fast in the 
 wound by buried sutures, which pass through the pillars 
 of the ring and th(^ ligament, after which the redundant 
 part is cut off, and the external wound closed. 
 
 Intra-peritoneal shortening of the round ligaments. 
 Wi/lie''s method. After opening up the abdominal cavity, 
 the round ligaments are brought into view and denuded 
 on their inner surfaces. Each round ligament is then 
 doubled on itself, and the loop retained in position by the 
 introduction of ligatures, after which the abdominal 
 wound is closed. 
 
 Vaginal fixation. Vaginal hysteropexy. With the 
 patient in the dorsal position, and an Edebohls" speculum 
 inserted, a median incision is made in the anterior 
 vaginal wall, from the neck of the bladder to the cervix, 
 after which the bladder is carefully separated from the 
 uterus and vagina as far as the peritoneal reflection. The 
 anterior surface of the replaced uterus if; drawn freely 
 forward by means of bullet forceps, and stitclied to the 
 incision in the anterior vaginal wall. This operation hau 
 now been practically abandoned. 
 
DISEASES OF THE L'TERUS — DISPLACEMENTS. 253 
 
 Ventral fixation. Abdominal hysteropexy. Tliif* 
 mc^thod consiKts in opc^niug tlic nbdoiuiiml cnvity. nnd 
 suturing the body of the uterus to th(3 nnterior abdomiuul 
 wnli. This operntiou has^ proved very satisfactory, both as 
 to its performance and results, and the only serious 
 objection which can be raised to it is the influence 
 which it will have on pregnancy and labor. From care- 
 fully prepan (1 statistics, it has been shown that women 
 subjected to this operation are less apt than others to 
 become pregnant; that pregnancy and labor are, as a rule, 
 uncomplicated. Inertia uteri is, however, not infrequently 
 met with, and serious or insuperable objections to labor 
 may be produced if the fundus and nnterior wall of the 
 uterus are imprisoned below the point of attachment 
 between the uterus and abdominal wall. 
 
 Various methods have been (U^vised for introduction of 
 the sutures, to avoid difficulties arising during pregiumcy 
 and labor. Kcllij',^ method consists in suturing the uterus 
 at th(3 junction of the fundus and posterior wall, to the 
 abdominal wall, with buried silk sutures. In this 
 techniqu"^ the sutures which suspend tho uterus embrace 
 only the peritoneal coat of the abdominal wall, and are 
 introduced superficially through the uterus. OUhlumaen 
 sews the cornua to the abdominal wall by means of silk- 
 wo m gut buried at the aponeurosis, the anterior rather 
 than the posterior surface of the fuiulus being included in 
 the sutures. Leopold uses silk sutures passed through 
 the entire thickni'ss of the abdominal wall, one at each 
 cornu, and tlu^ third between them. The sutures are 
 passed through the anterior rather than the posterior 
 surface of the fundus, and to ensure firm attachment the 
 peritoneum of the fundus is scraped oft*. Aft(^r fixation 
 the abdominal wound is closed in the usual way. 
 
 Latero-versions and latero-flexions are cuther con- 
 genital or acquired. In either case they occur through 
 shortening of the broad ligament on the side towards 
 
254 
 
 MEDICAL AND SURGICAL OYNJICOLOGY. 
 
 which the body tips. The only renl importance of theso 
 displncomonts, particularly floxions, is the production of 
 sterility. The diagnosis can be readily mad(> by bimanual 
 examination and by the sound. No treatment, unless that 
 of persistent taniponading of the vagina to stretch the 
 contracted ligament, offers any reasonable chance for 
 success. 
 
 PROLAPSUS. 
 
 Prolapsus is a displacement of the uterus in tlie axis 
 of the pelvic outlet. Three degrees liavo been described. 
 In the first degree there is simple ilescent in the axis of 
 the pelvic outlet, the cervix touches the tloor of the pelvis, 
 
 Fig. 78. — Procidentia uteri. 
 
 the fundus is pi oportionately below its normal level, and 
 the uterine axis slightly inclined backwards. Neither the 
 bladder, rectum, nor the vagina is necessarily involved. 
 In the second degree, the external os approaches the 
 vaginal orifice, the body of the uterus is retroverted and 
 lies in the sacral excavation, and usually the anterior 
 vaginal wall, together with the posterior wall of the 
 bladder, accompanies, if it does not precede the prolapse. 
 In the third degree, the cervix protrudes from the vulva 
 
riSEASliS OF THE I'TEKUS — IJISFLACEMENT.S. 255 
 
 moro or loss (i)r<)('i<l<'uti(i), evoii to tlio extent of the 
 ciitiro extrusion of the uterus. The anterior vnginal wftll 
 and posterior wall of the bladder, down to the meatus 
 urinarius, protrude from the pelvic cavity, and in a very 
 large proportion of cases the posterior vaginal wall and 
 the anterior wall of the rectum are prolapsed to the same 
 extent. 
 
 Causes. Of the indirect causes, laceration, over- 
 distention, or subinvolution of the perineum after 
 parturition is the prime element in the weakening of the 
 pelvic floor that eventuates in displacements of the jjelvic 
 contents. Varying conditions of the vaginal walls arising 
 from over distention or lack of tonicity, and relaxation of 
 the ligaments persisting for some time after parturition, 
 increase as well as facilitate the tendency to descent. 
 Absorption of adipose tissue, such as that which occurs in 
 those suffering from wasting disease, also lessens the 
 natural support and renders its desc«Mit more easy. 
 Among the conditions which operate more dirt^ctly may 
 be mentioned enlargement of the uterus. If. after partu- 
 rition involution is not complete, or if the organ is hypor- 
 trophied as a result of chronic metritis, or enlarged from 
 development of neoplasms in its walls, the increase in its 
 weight, favored by some of the indirect causes mentioned, 
 is almost certain to end in prolapse. One of the most 
 common causes is frequent parturition. A large majority 
 of cases of prolapse occur in women who, after one or more 
 severe child-births, are unable to remain at rest for a 
 sufficient l(Migtli of time to allow the pelvic organs to 
 regain their normal tone. 
 
 (Jomplicafio)is. In extreme cases, not only has the 
 uterus descended, but the bladder and rectum will b(^ found 
 displaced, and the ovaries will have descended into the 
 pelvic cavity to the depth of Douglas' pouch. In its 
 descent a chronic metritis may take place, by which the 
 walls are thickened and indurated, and the endometrium 
 
256 MEDICAL AND SURGICAL OYNJICOLOGY. 
 
 oxpaiidod ftiul vnscular. Ouo of tlui most comiiK m oom- 
 plicintioiiH is Incorntioii niid ovorsion of the lips of tlui 
 cervix, and often accompanied by a lacerated perineum. 
 Hypertrophy of the cervix in also a common occurrence, 
 in consequence of the irritation produced by the laceration. 
 When prolapse is compU>t(i the vaginal walls b(>come 
 smooth, dry, and are deprived of their rugosities, and in 
 cases of long standing the epithelium in places takes on 
 the appearance of the epidermis. Imperfect evacuation 
 of the distended bladder leads eventually to cystitis, and 
 the rectum may be the seat of irritation and of undue 
 accumulation of fecal matter. 
 
 Sijtnptoiiis. In cases which develop gratlually tlu^n; 
 may be no decided symptoms at first, but .soon ba(!ka(^ho 
 and a bearing down, dragging sensation about the vulva, 
 with a disagreeable feeling of weakness or want of support, 
 is noticeable. Difficult urijiation and defecation, find 
 even the symptoms of cystitis, are often prominent. The 
 diagnosis of prolapse of the uterus is excteedingly easy. 
 The examining finger will readily determine that the 
 cervix is lower in the pelvic cavity than it should be, or 
 that it is protruding through the vulva. Bimanual exam- 
 ination will indicate that the fundus is absent from its 
 normal position, and eitluT retroverted, or low down, at or 
 near the pelvic outlet. Accompanying prolapse in th(« 
 second degree will be found cystocele, and in the third 
 degree both cystocele and rectocelo. 
 
 Tri'dtmcnt. The treatment of prolapse is either palli- 
 ative or radical. Minor degrees of recent origin may be 
 treated by astringent injections and by tampons inserted 
 into the vagina in the genu-pectoral position, and later by 
 the ins(>rtion of a retroversion pessary. In the more 
 advanced degrees of prolapse, mechanical and palliative 
 means will be found of doubtful benefit, but treatment by 
 means of them may be made when operations are inad- 
 missable. A large soft rubber ring, or pessaries inflated 
 
DISEASES OF THE I'TEKUS - DISPLACEMENTS. 257 
 
 w'ifli Jiir, or mado of (Onstifi \vir(\ will sonu'timos rctniii i\ui 
 uterus ill tlu^ p(>lvis by (listciidiuj^ i\\v uppcT part of tlii^ 
 vagina. In most cases of (Hinipli'tc prolapst', it is necessary 
 to use n supporter composed of a c,v\ and stem pressing 
 against the vaginal portion of tlu> uterus and fastened 
 billow to an abdominal belt. The wearing of it is, however, 
 often very annoying and fre([Uontly causes excoriations 
 and ulcerations. 
 
 ()j)('i'(ifir(' fi-c(if)iiciil. This consists in applying m(>thods 
 for the diminution of the size of th(^ uterus, for 
 restoring the tone of the utt>rine ligaments, and for the 
 repair of the uterine supports. Tliese may be accomplished 
 by amputation of the cervix if it is much hypertrophied; 
 by repair of a laceration in it; and by thorough curettage; 
 all of which can b(^ completed at one sitting, aftl^r whicrh 
 the liganuuits will probably regain their tonicity. The 
 round ligaments may be made at once to renitw their 
 support by Alexander's operation for shortening them, 
 already describ(>d. 
 
 INVERSION OF THE UTERUS. 
 
 By inversion is meapt a more or loss complete turn- 
 ing inside out of the body of the uterus. There may be 
 simply a folding in of tlu^ fundus, or a projection of the 
 fundus through the dilated cervix, or a complete inversion 
 of both uterus and cervix. 
 
 Inversion comes under observation at three different 
 periods: Immediately after the occurrence of the accident, 
 or that form appearing during or immediately after child- 
 birth; second, about six weeks after labor; and third, that 
 which occurs after a lengthened period, often many years. 
 Leaving out the first form, which belongs more to the 
 subject of obstetrics, two classifications may be made: 
 Inversion (liirhu/ inroinfioiinnd inversion ((ff<'r involnfion. 
 
 The predisposing causes are, an enlarged uterus and 
 a relaxation or an inability on the part of some portion of 
 
258 
 
 MEDICAL AND SUIKHC'AI GYNECOLOGY. 
 
 Fig. 79— Incomplete Fk;. 80 —Complete 
 inversion of inversion of 
 
 t\w utcriin' wall to (U)iitnutt, hucIi rh oxists nt tho plno,(4ital 
 Hit(^ nftor labor, or at tlu^ phwv of orij^in of a hohhIK' iiitra- 
 utoriiio tibro-myoma. When hucIi (toiulitioiiH exist, 
 umiHual utorino coutraotioii may tako i>lac(% by which the 
 weaki'iied area is depressed and inverted, and the first 
 
 sta^e of inversion is initiated. 
 Subsequently a species of peri- 
 staltic movement, proceeding 
 from above downwards, is set 
 up in the uterine muscular 
 coats, until inversion becomes 
 nion^ or less complete. 
 
 Sijnipfomn. The chief symp- 
 tom for which n patient pre- 
 sents herself, is repeated hem- 
 orrhage, which may already 
 have undermined the constitution by its frequent recur- 
 rence or profuseness. To this symptom are added leucor- 
 rh(ua, dragging pains, and diffiv ulty in walking. Physical 
 examination will reveal tlu^ peculiar condition 
 present. When involution has not taken jilace, 
 or is not complete, the peritoneal cup formed 
 by the depressed fundus contains all, or a large 
 portion of the uterine appendages, and may 
 also contain loops of intestine. The inverted 
 uterine body projects into the vagina as a 
 large soft, more or less spongy mass, upon 
 which ran be discovered small depressions 
 corresponding to the orij,in of the Fallopian 
 tubes, and from the surface of which blood 
 seems to slowly ooze. Inversion after invo- 
 lution has neither intestine nor uti^rine appen- 
 dages in the cup. except the ends of the 
 Fallopian tubes and the ovarian ligaments. 
 The inverted body is firm, pear-shaped, and hangs 
 out of the cervix like a fibroid polypus. The mucous 
 
 Fk;. 8i~I'olvpus 
 simiiKitini; com- 
 plete inversion of 
 uterus. 
 
DISEASES OP THE UTERUS — DISPLACEMENTS. 
 
 259 
 
 nuMnhmiio roH<imbh<H ^ramilntion tissiu*, mid from it 
 lu'inorrhago tnkoH plmus but not to such an ^^\tont as in 
 tlio proviouH form. 
 
 I)i(((/n<>sin. Prolapse of the uterus and hyiMirtrophy 
 of the cervix might be mistaken for inversion. In tht^ 
 former the os is found in its normal place, through whicli 
 the sound readily enters, and the tumor is broader above 
 than below, the reverse being the case when invc^rsion is 
 present. A fibroid polypus with a h rge pedicle might 
 cause an error in diagnosis. In inversion the uterus is 
 darker and softer than a fibroid, and the 
 sound introduced between the body and 
 cervix discovers no opening into the 
 uterine cavity. A fibroid can be slightly 
 twisted on its long axis without twisting 
 the cervix; in the case of inversion this 
 cannot be done. With a fibroid, biman- 
 ual and rectal examination reveals the 
 fundus of the uterus at, or near its 
 proper place. In inversion there is an 
 abisence of the fundus, and a cup-shaped 
 depression occupies its plac(\ 
 
 Trcdfmnit. Inversion should, if pos- 
 sible, be reduced as soon as recognised. 
 The methods for reduction are mtmiud, iustrioncntdl, and 
 opcrdtive. 
 
 Manual. The fingers of one hand, formed so as to 
 make a cone, are inserted into tlie vagina and the tip of 
 the cone pressed against the summit of the inverted uterus, 
 or alternately against one uterine cornu and then the 
 other, while the other hand exerts counter-pressure, or 
 with the fingers attempts to dilate the ring through the 
 abdominal wall. 
 
 Emmet describes a method of reduction in the follow- 
 ing way : The hand is passed into the vagina, and, 
 with the fingers and thumb encircling the portion of the 
 
 Ki<i. 83.--Kil)rous [jolypus. 
 
260 MEDICAL AND SURGICAL ftYN/ECOLOGY. 
 
 body olosi' to tlio st^at o^ inversion, the fundus is allowi^d 
 to rest in tlio palm of the hand. This portion of the body 
 is firmly grasped, pushinl upward, and the fingers immedi- 
 ately separated to tluur utmost; at tlu^ same time the 
 other hand is employed over the abdomen in the attempt 
 to roll out tlu> parts forming the ring, by sliding the 
 abdominal parit^tes over its edge. This manoeuvre is 
 repeated and continued. At length, as the diameter of the 
 uterine cervix and os is increased by lateral dilatation 
 with the outspread fingers, the long diameter of the body 
 of the uterus b( -oLies shortened and tiie degree of inver- 
 sion proportionately lessened. After the body has 
 advanced well v/ithin th'> cervix, steady Qjjward pressure 
 upon the fundus is applied by the tips of all the fingers 
 brought together. 
 
 Iiistrumciital. Ingenious minds have devised instru- 
 iTients by which a steady pressure can bv effected upon the 
 inverted fundus, while counter- pressure is exercised upon 
 the cervical ring. By the use of i ich instrumenl,s re- 
 position of the organ lins been effected in less than twenty 
 four hours. A more sim])le method consists in packing 
 the vagina witli gar.ze in such a manner that the fundus 
 will be pressed upward, in tlie direction of the axis of the 
 superior s':rait, whih' the dihited wall of the vagina 
 makes traction upon the c(>rvix. 
 
 Opcvdtivc. Tlie only operative measures for thc^ reduc- 
 tion of the inverted uterus is that proposed and carried 
 oat first by Dr. Tliomas. It (;onsists in opiming tlie 
 abdomiiml cavity, stretching the ring witli a kind of glove 
 stretcher, while the hr..".'' iiitroduced into the vagina forces 
 the fundu,; throu.;h the rii\g. and up into its normal plawi. 
 Should efforts by this method fail, resort nmy be luul at 
 once to hysterectcnny to relit^ve the distressing as well as 
 dangero\is condition. Amputation of the inverted uterus, 
 preferab by the elastic ligature, is aLso recommended 
 v.heT other less radical methods hav^ failed. 
 
DISEASES OF THE UTERUS — BEN'IGN NEOPLASMS. 261 
 
 CHAPTP]R XXIV. 
 
 DISEASES OF THE UTERUS CONTINUED. 
 HENKiN NEOPLASMS. 
 
 Cysts in the cervical canal are of common occur- 
 rence and arc erroneously called ovules (>f Nabotli. Like 
 cipher cysts lined with epithelium, ihey orij^inate from 
 glandular formation, and are thus a species of adenoma. 
 The contents are li([ui(l. semi-li(|uid, or form a jelly-like 
 mass. The tit'atment consists in opening them, and 
 touching the interior with tincture of iodine. 
 
 Myxoma. Glandular polypus. All so cnlled polypoid 
 tumors of a jelly-likt^ consistency, and half translucent to 
 the naked eye. appear under the microscope to be made 
 up mainly of myxomatous tissue. They are found most 
 fre(piently in the cervix, and are usually sessile at first, but 
 have a tendency to become pedunculated nnd protriulo 
 through the os as bluish or purplish red lobules. The 
 symptoms which usually attract attention are leucorrluna 
 and luunorrhage, and. on examination, a small iumor will, 
 perhaps, be seen i^rotruding through the o.s. The treat- 
 ment consists in removal with the curette if intra-uterine, 
 and in torsion if cervical. 
 
 FIBROMATA. 
 
 To those tumors of the uterus which have the .same 
 structure as the uterus itself, the names ol Jihroiud, mi/oma, 
 Jihvoiis fiitHO" find Jihi'oids li::ve been given, and from the 
 fact that tlu^y are generallj^ of the mix(>d variety, com- 
 posed of muscle fibres and fibrous conniM'tivi' tissue, the 
 corresponding terms inj/o-Jihi'oiiKi or Jihro-DiijonKi have 
 been applied. They are usually benign, that is to say. 
 incapable^ of becoming g(>neral and infecting t'u' org.'inism. 
 but they are not .so harmless as the older ...thors con- 
 
262 
 
 MI5I)K!AL AND SURGICAL GYNECOLOGY. 
 
 ;. 83. — Interstitial 
 fibroids. 
 
 Fit;. 84. — Subserous 
 and su))Miucous 
 fibroid. 
 
 siderod tliom to be. Tlio knowlwlgo of tlio orijjin of these 
 tumors is still very imperfect. Klobs asserts that they 
 have tlieir origin in n pro- 
 liferation of the connective 
 tissue and muscular layers 
 of certain vessels. Another 
 authority asserts that they 
 ar(> due to a round cell found 
 alonj^ the capillaries, which 
 by growth obliterates them ; 
 the cells then become fusi- 
 form and produce nodules, y 
 
 The tumor may consist of 
 one mass, or of several dis- 
 tinct masses, developed side by side, and enclosed in a 
 single capsule, or many tumors with individual capsules 
 may be scattered throughout the uterine walls. They 
 vary in size from a tumor the size of a pea to a growth of 
 immense proportions. The majority have their origin in 
 the body of th3 uterus and most often are situated in the 
 posterior wall; least frequently they spring from the 
 cervix. They are classified according to the relation 
 which the tumor bears to the uterine tissues. 
 
 The iiifcrsfiti'dl develop within the uterine walls, and 
 are surrounded on all sides by iterine muscular tissue. 
 
 The finh-miic(>ut^ develop imme(\ately o** just below the 
 mucous membrane, and project into the uterine cavity 
 without becoming pendulous <^sv'.s'.s'/A'). 
 
 The poli/itoid have their origin under the mucous 
 membrane, on the surface of the muscular wall, from 
 which they project more and more, as they grow, until 
 they bec(^me i>endulous. 
 
 The sKb-pcrifoncdJ or siih-scrous develop upon, or near 
 the external surface, under the peritoneum, and either 
 project upon the suiface, or become pedunculated. 
 
DISEASES OF THE I'TEUrS- BENIGN NEOPLASMS. 2{)li 
 
 Th(i I'litrd-liutnuciiloiis. nn iiuportaiit sub-vuricty, 
 develop in the thickness of the broad ligament. 
 
 Htrnctun'. To the naked ey(^ thesi' tumors are eoni- 
 posed of dense tissue, shiny, or rosy whit(\ elastic, giving 
 a very clenu surface on section, and, when examined under 
 the microscope, exhibit varying i)roportions of connective 
 tissue and muscle Hbre irregularly intt'rwoven. Their 
 vascular supply is relatively scant, but they are apt to be 
 
 FiLi. 85 — Large pedunculated fibroid of uterus, i, cervical canal ; 2, 2, ovaries; 3, liliroid ; 
 4, fundus of uterus, (Krom the pathologic.1l lalxiratory, (Jueen's University.) 
 
 surrounded by vascular and hypertrophic uterine walls. 
 In tumors of considerable size, large arteries are sometimes 
 found under the peritoneum, or in the capsule, and wIumi 
 such n condition exists the peripheral veins arc> sometimes 
 th(> size of tlu' jugular, and adherent on all sides to the 
 muscular bundU^s which hold them wide ()i)en. WIumi 
 this arrangement is well marked and the tumor hollowed 
 out by vascular lacunu3 due to dilatation of the capillaries, 
 
264 
 
 MEDICAL AND SURGICAL UYN/EC(lLOGY. 
 
 tliere exists what Vircliow calls '• tolcaii,i^i('('tatic myoma." 
 or " myomn caveriiosum,'' the portion degciierated resem- 
 
 FlG. 86. — Kil)ro-cyslic tumor of uterus. i. Incision in wall of l?.rge cyst, i, a. Interior of 
 cyst. 3. Small cyst. 4. lUerine cavity. 5. Multiple fil ro-myom.T. (>. "undus of 
 uterus. (From the pathological lalioratory, Queen's University.) 
 
 bliiig a sponge soaked in blood. Polypoid tumors some- 
 times contain large blood vessels, but when removed the 
 
DISEASES OF THE UTERUS — BENIGN NEOPLASMS. 265 
 
 contractility of tlio walls usunlly brings about rapid 
 hsemostasis. 
 
 AUerdtioa <ind (legcywrdtion. At the mcniopauso most 
 of the fibromata undergo a progressive induration and 
 diminution in volume, and in such a state often persist 
 without causing any morbid reaction. Very rarely they 
 undergo calcification by a deposition of carbonate of lime. 
 During sexual activity they may undergo changes depen- 
 dent upon physiological processes. During pregnancy a 
 marked increase in size is sometimes noticed, due princi- 
 pally to changes in the circulation causing cedema of the 
 growth. CEdema occurring in tumors existing in a non- 
 pregnant uterus is frequently the forerunner of gangrene. 
 Fatty degeneration is very rare, and where suppuration 
 exists, it is for the most part the outcome of gangrene. 
 
 Cystic derfeneratiofi is a peculiar process of liquefac- 
 tion characterized by a primary serous infiltration and 
 associated with myxomatous softening of the growth, 
 accompanied by an oedeniatous swelling of the connective 
 tissue, followed by more or less disintegration. When 
 advanced, these changes result in the formation of spaces 
 tilled with linid, the walls of which are formed by the non- 
 disintegrated portion of the tumor. At first the muscular 
 bundles prevent the formation of large cavities, and give 
 to the cyst wall a peculiar uneven appearance, like the 
 columnse of the heart. Subsequently, however, tliese also 
 become disintegrated and large spaces are formed. 
 
 The contained fluid varies in color, from a pale amber 
 to a dark brown, the changes in color being due to 
 extravasation of blood. The fluid, as a usual thing, 
 coagulates spontaneously, and chemical and microscopic^al 
 examinations show it to contain serum-albumen and 
 fibrin, with more or less mucin, blood, and detritus from 
 degenerated tissue. 
 
 Etiolo()i). Although much attention has been paid to 
 the causation of these neoplasms it must be admitted that 
 
266 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 little or nothing is known. No single cause assigned has 
 been proved with reasonable certainty. 
 
 H]imptows. Small subserous tumors sometimes exist 
 without causing any .symptoms. Hemorrhage, either 
 monorrhagia or metrorrhagia, is common to nearly all the 
 fibromata. In the polypoid and submucous varieties it is 
 the most noticeable symptom. In the interstitial variety 
 it is less frequent, while in the exclusively subserous it is 
 very often absent. More or less profuse leucorrhoea, and 
 intermittent watery discharges are also present in the 
 majority of patients. A symptom of equal importance is 
 pain, at times of an intermittent character, and most 
 intense during menstruation. It may arise from painful 
 uterine contractions due to the presence of polypoid 
 tumors, or to retention of secretions; from pressure of a 
 polypoid or submucous growth at or near the internal os; 
 or it may be due to pressure upon the surrounding pelvic 
 tissues, or upon the bladder, rectum, or sciatic or gluteal 
 nerves. Pressure on the rectum may cause obstinate 
 constipation; pressure upon the bladder, vesical disturb- 
 ances; and on the ureters, retention of urine in the pelvis 
 of the kidney, with subsequent renal changes. Pregnancy 
 is not infrequent, and should it occur the tumors are apt 
 to grow more rapidly, but after partiirition they may 
 comijletely disappear. 
 
 Course. Fibromata in most cases run a benign course. 
 They grow slowly and seldom cause death directly. As 
 has been already stated, they often undergo progressive 
 induration and diminution after the menopause. If 
 polypoid thoy may be expelled by the vagina. Multiple, 
 interstitial, or submucou.s tumors may attain a great mzQ, 
 but when a large number start simultaneously, intermediate 
 pressure tends to cut off the blood supply and arrest 
 growth. Submucous and interstitial tumors may become 
 gangrenous, followed by suppuration, and when such a 
 
DISEASES OF THE UTERUS — BENIGN NEOPLASMS. 267 
 
 course is pursued death may follow from peritonitis, 
 septioasmia, or pyremia. 
 
 I)i<((/)iosis. Single interstitial, submucous, and poly- 
 poid fibroids, if of moderate size, may be mistaken for 
 pregnancy, retained menses (luematomotra), malignant 
 disease, or subinvolution. A fibroid uterus is harder to 
 the feel than in pregnancy, and the os, although some- 
 times slightly dilated, is not softened or deepened in color, 
 and there is absence of the familiar signs of pregnancy. 
 A large polyjjoid growth often dilates the cervix, and may 
 be felt presenting at the os. In ha^raatometra the retained 
 discharges give the uterine walls a tense elastic or fluctu- 
 ating feel, and, on examination, the internal or external os 
 will be found impermeable, and perhaps the menses will 
 have never appeared. In malignant disease, tlu^ age of 
 the patient will assist in making the diagnosis. The 
 peculiar offensive discharge is characteristic, and if in 
 doubt curetting and examination with the microscope will 
 make the condition clear. 
 
 Subinvolution generally produces cervical, as well as 
 corporeal enlargement, the body is flatter, the antero- 
 posterior diameter being not so much increased as when 
 fibroids are present. Interstitial multiple tumors cause 
 the uterus to enlarge more or less irregularly, and make 
 the canal to become so tortuous that n probe can with 
 diflficulty be passed, or even not at all. When the tumors 
 are near the outer surface, the probe may enter readily the 
 full length of the canal, but bimanual examination will 
 disclose the hardened projections on the outer surface of 
 the uterus. 
 
 Retro-uterine hematocele and ha?mHtoma may be differ- 
 entiated by bimanual examination and by tlu> use of the 
 sound. In such cas(^s the uterus will likely be found in 
 front of. or at one side of the tumor, or it may be pushed 
 up behind the pubes, where it can be moved indep«>ndeiitly 
 of the mass. A small subserous tumor, if pedunculated. 
 
268 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 may bo miHtnkcMi for a diHoasod ovary. Tho formor is 
 usually tinner to the touch than Ih tlu^ ovary, lias a 
 smoother surface, and is not siMxsitive on bimanual 
 pressure, and the pedicle may be palpated. A tumor 
 partially extruded from the os may be mistaken for cancer, 
 especially when the former is gangrenous. In both cases 
 there is profuse vaginal discharge, but witli care tho 
 cervix may be shown to surround the protruding mass. 
 Fibro-myomata of the pelvic variety may resemble pelvic 
 exudations, but if the tumors are not adherent they can 
 be displaced by the examining fingers. They do not 
 encroach so closely upon the pelvic wall, and are generally 
 harder to the touch. Intra-lignmentouH fibroids are dis- 
 tinguished by their close connection with the uterus, and 
 their unyielding feel to the touch Cervical fibroids are 
 usually easily recognised by the protuberance in the lip 
 affected, and the fiattened appearance of tho opposite lip. 
 
 Treatment. This may be divided into pdlUdiivc and 
 r(uliv(d; or mc.dicdl and nunjicdl. It may be stated at tho 
 beginning, that a serious operation should never be under- 
 taken just because a woman has a fibro-myomatous tumor, 
 the growth must in some manner menace life or health, 
 and not be amenable to other treatment. It may also be 
 stated that all medical treatment is absolutely ui.;?les8 in 
 pedunculated subserous tumors. 
 
 The hypodermatic use of crffot has, in some cases, 
 caused a cessation of growth in interstitial tumors, and 
 even their extrusion, and is therefore applicable for the 
 treatment of such growths, as well as the submucous 
 variety. The effect of ergot is to cause comprestJon of 
 the blood vessels, by producing more or less marked 
 contraction of the muscular structure of the tumor. The 
 drug should be used in the form of ergotine, from one to 
 two grains being injected into the fleshy part of the thighs 
 or buttocks twice daily, the dose being governed largely 
 by the uterine pain produced. Instead of hypodermatic 
 
DISEASES OF THE UTERUS— BENION NEOPLASMS. 269 
 
 inj(>ctions, dram doses of fluid extract of ergot, or two 
 grain capsules of ergotiue may bo given by the moutli 
 three times daily, or if it disagrees with the stomach, it 
 may be mixed with four ounces of water, and administered 
 by the rectum. Fluid extract of hydrastis, in half dram 
 doses, may also be used with benefit, but the chief 
 advantages from its use lie only in the effect it has in 
 checking hemorrhage. The bromides and iodides, arsenic, 
 mercurials, and such like, do not possess any positive 
 therapeutic value. 
 
 Among recent remedies (jdhxinism plays an important 
 part, especially the method introduced by Apostol; The 
 method of application,'and the benefits to bo derived from 
 this class of treatment, has already been referred to when 
 speaking of the practical application of electric currents. 
 
 Subperitoneal tumors, tilling the pelvis and causing 
 much distress, can at times be dislodged by pressure 
 upwards through the vagina, with the patient in the genu- 
 pectoral position. Hemorrhage may be treated by dilata- 
 tion of the cervix, repeated curettage, and subseciuent 
 application of tincture of iodine, or carbolic acid to the 
 endometrium. 
 
 Beside the administration of ergot to diminish the 
 blood supply, an operation for li<j(dure of the uterine 
 nrterios, for a similar purpose, is recommended as giving 
 beneficial effects on many tumors, the peduncalated and 
 subperitoneal excepted. With the patient in the dorsal 
 position an incision is made on either side of the cervix, 
 and the connective tissue pushed away until the uterine 
 artery can be felt pulsating. A pedicle needle, armed 
 with a ligature and guarded by the finger, is passed from 
 behind forwards through the broad ligament, above the 
 artery, and after the withdrawal of the needle, the ligature 
 is tied. The artery on the opposite side is tied in the 
 same way, care being observed in each case to avoid the 
 ureters. 
 
270 MEDICAL AND SURGICAL OYNJICOLOOY. 
 
 Ooplinrcctomif. It lins been stnted that at tlu^ iiuiiio- 
 pnuse, uterine tumors may undergo retrograde* cliangc^s, 
 and that the symptoms produced by them may gradually 
 disappear, when menstruation has ceased. With this end 
 in view, oophorectomy is frequ(uitly performed to bring 
 about the menopause prematurely and, if the case has 
 been properly selected, will likely produce the desired 
 effect. 
 
 Large tumors, those which are soft or cedematous, pure 
 submucous growths, subserous ones with broad bases, 
 tibro-cystic growths, or those which produce painful 
 pressure symptoms, should not be treated by this 
 operation. Cervical fibroids are not amenable to palli- 
 ative treatment, and should be removed. When peduncu- 
 lated and small, they may be twisted off; if large, and the 
 pedicle thick, the mucous membrane may be incised all 
 around close to the cervix, and the remainder of the 
 pedicle cut through, after which the mucous membrane is 
 stitched over so as to close in the stump. When sessile 
 or distinctly submucous, the capsule should be incised 
 and the tumor enucleated. After trimming the margins, 
 the raw surfaces are coaptated by deep sutures. If unable 
 to do this, or if there is troublesome hemorrhage, the bed 
 of the tumor, and the vagina as well, should be packed 
 with iodoform gauze. Intra-uterine polypi, smaller than 
 a child's head, may be removed in the same way as the 
 cervical, the cervix having been previously dilated to such 
 an extent as will permit the extraction of the tumor. In 
 cases where the attachment of the pedicle is high up, or 
 difficult to reach, or where there is fear of hemorrhage, a 
 pair of light forceps may be clamped on the pedicle at its 
 attachment to the uterine wall, and the pedicle cut through 
 with scissors. The forceps, carefully surrounded with 
 gauze, are allowed to remain in situ for some hours, when 
 they may be removed. 
 
DISEASES OF THE UTERUS — BENKiN NEOPLASMS. 271 
 
 The nature of further operations for utoriuo fibromntu 
 will vnry ncconliug to tho situntiou niul nttnchmout of tho 
 tumorH. Tlioy may bo thus clnssifiod: 1. iiimjAc myomrc- 
 tornij, or romovnl of the tumor without any of the uterine 
 tissue by excision or enucleation. 2. Hysto'cctoniij, tot((l 
 or pdi'ildl, or removal of more or less of the uterine tissue 
 with the tumor. 
 
 Myomectomy. When it is jw^sible to remove the 
 tumor from the uterus without destroying the organ, it 
 should be done. The operation is called myomectomy, 
 and is suitable for all subserous growths, and for such 
 interstitial ones as can be enucleated without entering the 
 uterine cavity. 
 
 The (ibdomiiKil incision. The operation for opening 
 the abdominal cavity has been known by various terms, 
 (jastrotoniy, \ap<ir(itomy, and (ihdominal section, but 
 lately the term ecvliotomy has been introduced, which, 
 while more fully expressing the meaning to be conveyed, 
 is classically correct. The incision should be made in the 
 line of the linea alba, between the umbilicus aiid symphysis. 
 After incising the skin and adipose tissue, the aponeurosis 
 is reached, i nd after carefully dividing this structure the 
 recti muscles are brought into view. These are next 
 separated in the median line, exposing the subserous 
 areolar tissue. After cutting through it, and the peritoneum 
 brought into view, the latter is picked up between two pairs 
 of forceps and incised with the point of a scalpel. It is 
 best to make the first opening not more than two and a 
 half inches long, as subsequently it may be enlarged, 
 should circumstances demand it. Care must be taken not 
 to incise too lo>^^ lest the prevesical space be opened or the 
 bladder wounded. 
 
 After the abdominal incision is complete the libro- 
 myomatous uterus is brought up, if necessary, partially 
 or wholly through the wound. If there be danger of 
 copious hemorrhage, an elastic ligature may be placed 
 
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272 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 around the uterus and broad ligaments, below the tumor 
 or tumors to bo removed. When the pedicle is large its 
 capsule may be incised a short distance from the uterus, 
 its fibrous tissue enucleated, and the capsule sutured over 
 the base firmly enough to check all oozing. In some 
 cases it is easier to cut the pedicle wedge-shaped, with the 
 thin edge extending up to, or into the uterine wall, and 
 sew up the flaps that are left with deep and superficial 
 rows of sutures. A subserous Lumor without a pedicle 
 may be enucleated and its bed sewed up in a similar 
 manner. 
 
 Closure of the (ihdominal incision. Strict attention 
 should always be paid to the proper closing of the wound 
 in the abdominal parietes. The methods vary much, but 
 they all aim chiefly at avoiding the subsequent occurrence 
 of ventral hernia. Three loading principles should be 
 observed in order that good results may follow. The 
 apposition of the raw surfaces sh./.M be as broad as 
 possible. Each divided structure should be placed and 
 kept opposite its fellow, peritoneum with peritoneum, 
 muscle with muscle, fascia with fascia, fat with fp.t. The 
 sutures should not bo removed too early. The material 
 used for suturing may be divided into absorbable and 
 non-absorbablo agents, the chief among the former being 
 catgut and kangaroo tendon, and among the latter, silk- 
 worm gut and silk. 
 
 Methods. Suture in mass or through find through 
 suture. For this class of suture either silk-worm or silk 
 may bo used, but the former is tho one almost universally 
 adopted. The needle is inserted into the skin at the 
 upper angle of tho wound, about throe quarters of an inch 
 from tho margin of the incision, and, as it passes through 
 each layer — fascia, muscle and peritoneum — they are 
 separately picked up, so as to make certain of their being 
 included in the suture. The needle is carried through on 
 the opposite side in reverse order. The sutures are placed 
 
DISEASES OP THE UTERUS— BENIGN NEOPLASMS. 273 
 
 about throe to tho hicli, and, after nil nro inserted, the ends 
 ,Tro gathered up so as to bring the wound together care- 
 fully, and are then tied. Some operators make the sutures 
 include only the structures overlying the peritoneum, the 
 latter being left intact. 
 
 Buried or tiei- suture. For this purpose catgut or 
 kangaroo tendon is used. By means of a continuous 
 suture tho peritoneum is first closed. Next the muscular 
 layer is drawn together, next the fascial layer, and finally 
 the skin. 
 
 Comhined method. By this is meant the combination 
 of suture in mass and of the buried suture. When the 
 through and through sutures are being inserted a few 
 silk-worm sutures are passed through the aponeurosis 
 only, and when tied, are left as buried sutures. 
 
 Hysterectomy. By hysterectomy is meant partial or 
 total removal of the uterus. It is termed complete when 
 the cervix as well as the body has been removed; partial 
 when the cervix has been left. Some surgeons speak of 
 the operation as total htjstereetomij, even when the cervi'c 
 is left behind. Another division is made into extra- 
 peritoneal and intra-peritoneal, according as the pedicle 
 is treated outside or inside the peritoneal cavity. 
 
 Indications for operation. Mere bulk may of itself 
 bo a sufficient reason. Rapid growth or the development 
 of cysts in soft cedomatous tumors ; suppuration and 
 sloughing; excessive metrorrhagia which every palliative 
 measure fails to check; pressure on adjacent viscera pro- 
 ducing obstruction; uncontrollable pain; the presence 
 of abundant ascitic fluid, are all clear indications for 
 operation. 
 
 Besides tho instruments commonly used in coeliotomy, 
 special large forceps should be provided to clamp on large 
 vascular areas ; also two trustv^orthy clamps for the 
 constriction of the pedicle, and I'or tho latter purpose 
 Koeberle's serre-nonud, or Tait's modification of it, is 
 
274 
 
 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 probably the most efficient. The Trendelenborg is the 
 position most often used. After the abdominnl cavity lias 
 been opened, information is obtained as to the size, 
 position, relations and possible adhesions. By moans of 
 a large vulsellum, or myoma screws, the tumor is brought 
 up into the wound, and ligature of the broad ligament 
 proceeded with. When the tumor is well drawn up, these 
 ligaments will be put on the stretch. Eacl broad ligament 
 
 Fig. 87.— Application of ligatures in ablalion of the fibroid uterus. 
 
 is tied and divided, after placing pressure forceps on the 
 uterine sides, outside the ovaries and tubes. If the 
 ligameiits are very broad, two or even three successive 
 applications of the forceps, each below the previous one, 
 and as many ligatures, may be necessary. The tumor 
 being delivered as fully as its attachments to the vagina 
 and the lower portion of the broad ligament will permit, 
 the bladder is pushed well down under the pubes in front, 
 and sponges are packed in behind to keep the intestines 
 out of the way. 
 
 It must now be decided in what way the pedicle is to 
 be treated, whether extra-peritoneal or intra-peritonenl. 
 
 Extrn-peritoncdl treatment of the pedicle. The wire 
 of the serre-ncjeud is passed around the pedicle, care 
 always being taken to avoid the bladder, and, when drawn 
 
DISEASES OF THE UTERUS — BENION NEOPLASMS. 27o 
 
 uiJ, tho free ond is made fast to tho movonble pin and ?is 
 mucli constriction made, by turning tlio thumb screw, as 
 will arrest the circulation to its fullest extcuit without 
 cutting. Pedicle skewers are inserted across the incision, 
 either parallel or crucially, just above the wire, and the 
 tumor removed close to them, leaving only enough tissue 
 to give firm hold. In placing the serre-nooud, it should 
 be so arranged that the constricted wire will be well within 
 the parietal wound, and the handle so that it will lie over 
 the pubic region. There are other modes of constriction 
 besides the wire, such as the elastic ligature, and tho 
 clamp, but the method described seems to be the favorite 
 one. The parietal incision is closed in the usual way 
 as far down as the pedicle, tho lowest stitches being 
 inserted so as to draw the tissues closely around 
 it. The use of styptics, such at, icrchloride of iron 
 or the actual cautery, to the stump is x-ecommended by 
 some for their charring effects. Subsequently the wound 
 is dressed in the usual way. The whole stump above the 
 wire is removed in course of time by pressure necrosis, 
 but it is not necessary to allow the wire to remain for that 
 length of time, but may be removed as soon as the new 
 adhesions are sufficiently strong. Afti'r tlu pedicle 
 separates, a deep granulating excavation is left, which 
 rapidly fills up even with the skin. 
 
 Intrd-pcriiom'dl trcxdmod of fh'.> pedicle. The opera- 
 tion in its first stages is similar to that already described. 
 If there is fear of hemorrhage an elastic ligature, or wire 
 clamp, may be placed temporarily around the cervix, but 
 this procedure is scarcely necessary when the uterine 
 arteries have been controlled by the broad ligament liga- 
 tures. With the same precautions observed for tln^ care 
 of the surrounding structures as already described, an 
 incision is made a little above the attachment of the 
 bladder, and a corresponding incision behind, by which a 
 cup-shaped cavity is cut out and the tumor removed. 
 
276 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 Tho cavity thus formed in the cervix is now closed by 
 buried cntgut sutures, and by a separate row of silk to 
 unite the peritoneum. The abdominal incision is then 
 completely closed. 
 
 Complete hysterectomy. After ligature of the broad 
 ligaments according to the manner described, another and 
 lower deligation of them is carried out, great care being 
 observed not to include the ureters. The peritoneum is 
 next divided all around the cervix, below the constricting 
 ligature, if one has been used, avoiding carefully the 
 bladder in front and the rectum behind. An opening is 
 made on the top of the vagina, the point being indicated 
 by the insertion of a probe into that canal, and with a few 
 strokes of the scissors the division is completed as close as 
 possible to the cervix. After securing the few bleeding 
 points, the anterior and posterior flaps are united by a 
 continuous catgut or silk ligature. After carefully cleans- 
 ing out the peritoneal cavity, the parietal incision is 
 closed; should necessity demand it, drainage may be 
 established through the vagina. The vagina should next 
 be loosely packed with iodoform gauze and changed daily 
 after the second day. 
 
 CHAPTER XXV. 
 
 DISEASES OF THE UTERUS CONTINUED. 
 
 MALIGNANT NEOPLASMS. 
 CANCER OF THE UTERUS. 
 
 This disease occurs most frequently between the 
 ages of forty and fifty, although earlier periods of life are 
 not exempt. It was formerly thought that cancer was 
 limited to the cervix, but later experience has shown that 
 cancer of the body, although not so frequent as cervical 
 cancer, is not rare. 
 
DISEASES OF THE UTERUS— MALIGNANT NEOPLASMS. 277 
 
 Cancer of the cervix. Tho gront predisposition of 
 the cervix to the development of cancer hns been noticed 
 by all observers. More than one tliird of nil cases of 
 cancer in women occur in the cervices of inultipane, and 
 the frequency is explained by the fact that iho cervix is so 
 often subjected to irritation, laceration, ero.^'ion, and 
 infection. 
 
 Pdtholofi/i. From a clinical point of view, and when 
 seen at the start, and before the primitive aspects of the 
 part have been altered by their spread to adjacent struc- 
 tures, four classes may be distinguished. 
 
 1. PapiUarij. (Superficial cancer of the cervix, vege- 
 tative or cauliflower cancer.) This form begins on the 
 vaginal portion of the cervix, and may for a long time be 
 limited to it. Often it starts from cylindrical epithelium 
 which ha;i invaded the external surface. It may take on 
 a fungous appearance, the os and healthy lip being hidden 
 beneath it, and for a long time may show no tendency to 
 spread. Sooner or later, however, it attacks the cul-de-sac 
 and passes on to the peri-uterine tissues; or the extension 
 may take place along the cervical canal. 
 
 2. NoduJar. (Parenchymatous cancer, cancerous 
 nodosities, circumscribed or infiltrated cancer.) This 
 form starts as one or several nodules in the mucous 
 membrane of t'' j cervix, on either the external or internal 
 surfaces, witl ^-eration only late in the disease. In this 
 form the whole organ soon becomes involved, as well as the 
 adjacent tissues. 
 
 3. Cancer of the cdvifi/. (Boring or eating cancer). 
 This form develops first in the cervical mucous membrane 
 by an infiltration which soon ulcerates and causes the 
 slow destruction of the part by erosion, and there are 
 cases of this kind where the cervix becomes a mere shell. 
 The body of the uterus is early involved, then the peri- 
 uterine connective tissue, and the vagina last or not at all. 
 
278 
 
 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 4. Vdffi'ndl This is far moro oommon tlinu the otliors. 
 It begins in the postorior cul-de-sac and invades equally 
 the cervix and the adjacent j)ortion8 of the vagina, i^ro- 
 ducing extensive ulceration. 
 
 Histologically the three kinds most often found are: — 
 
 1. Pavemenf cjiitlicliormt (sciuamous epithelioma) is 
 that variety often found in the superficial forms — papillary 
 and vaginal. In the variety called lohnhdcd, cellular 
 masses lie between the bundles of muscular fibres. In the 
 tubulated, anastomosing cylinders, stuffed full of epithelial 
 cells, penetrate between the muscular trabecular. 
 
 2. Ctjiindn'cal epithet iomd is usually the form which 
 begins in the cervix and spreads along its cavity, and 
 resembles that of the uterine body. It begins by a 
 
 typical glandular proliferation 
 (adenoma), and ends as an 
 atypical proliferation ( malig- 
 nant adenoma), which is simply 
 an epithelioma. 
 
 3. Carcmomd or atijpirrd 
 epdiielioma is not clearly dis- 
 tinguished from certain forms of 
 tubulated pavement epithelioma. 
 It is characterized by poly- 
 morphism of its cells which 
 correspond to those of the al- 
 veolar wall, or to those of the gland ; also by their 
 disjoosition in masses within the alveoli, the walls of which 
 are formed by anastomosing bands of connective tissue. 
 When the fibrous stroma is small in amount, and the 
 cells are swollen and predominant, t' e tumor is called 
 enceplKiloid; when hard and dry it is called sct'ri-lius. 
 
 Extension. At an advanced period of the disease, the 
 characteristics peculiar to each form are lost in the 
 destruction caused by its extension. Extension to the 
 vagina may be found at the outset. It may occur rapidly 
 
 88. - Cylindrical epithelioma of 
 ihe cervix. 
 
DISEASES OF THL UTERUS — MALIGNANT NEOPLASMS. 279 
 
 in the pnpillr.ry form, and may oven ronch the vulvn. The 
 body of the organ is very soon involved in the case of 
 tumors of the cervical cavity, and, in the nodular form, 
 it may bo infected from the first. The pelvic connective 
 tissue may be invaded from the cul-de-sac, the cervix, or the 
 fundus, by which the uterus becomes imprisoned, as if set 
 in plaster of Paris, and the broad ligaments bocome thick- 
 ened and shortened. The ureters, instead of being pushed 
 aside, become assimilated by the neoplasm, and ulceration 
 and fistuhe may re- 
 suit; or they maybe- 
 come compressed 
 producing hydro- 
 nephrosis and allied 
 conditions of the kid- 
 ney. The rectum is 
 seldom involved, ex- 
 cept in far advanced 
 cases, when the vagina 
 may be found open- 
 ing both into the 
 bladder and rectum. 
 The peritoneum re- 
 sists the ingrowth by 
 the production of 
 adhesions, and is seldom opened. The ovaries and 
 Fallopian tubes may all become affected, and, lastly, there 
 may be metastases to distant organs, as the liver, kidneys, 
 stomach, and lungs. 
 
 Symptoms. The onset of the disease is insidious, and 
 may exist for some time while the patient preserves every 
 appearance of health. The earliest symptoms are in no 
 way characteristic. The attention h. often first attracted 
 by a small loss of blood at other than the regular periods, 
 or appearing at variable times after the menopause, 
 especially after some exertion, or after coitus. Leucorrhoea, 
 
 Fig. 89 — Epithelioma aflecting both lipsof Ltrvix, vagina 
 and bladder. 
 
280 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 without nny spocinl < hnractoristics npponrs. to^othor with 
 somo diffuse pelvic pniii. Such Hymptoms sliouid always 
 excite suspicion in one who has passed for some time the 
 climateric period, and a local examination insisted upon. 
 Digital exploration recognizes the induration, or the 
 papillary and ulcerated condition. The speculum tlemon- 
 Etrates the livid aspect of the tumor, the yellowish surface 
 of the ulceration and the fungous vegetations if present. 
 
 As the disease advances, hemorrhages become more 
 frequent. The vaginal discharge becomes reddish and 
 has a peculiar, characteristic, as well as disgusting odor, 
 and so abundant and acrid that it causes distressing 
 erythema of the thighs and pruritus of the vulva. The 
 local pain now becomes more or less severe, with radiation 
 of it in different directions. By digital examination the 
 vaginal pouches may be found invaded, the uterus more 
 or less fixed by extension of the morbid processes, and the 
 cervix changed by the advancing disease. 
 
 The third stage, or that known as the cancerous 
 cachexia, is indicated by digestive disturbances, anorexia, 
 constipation, and by the skin assuming a peculiar pale 
 yellow tint, and by becoming harsh and dry. At this time 
 there may be present cystitis, intolerable neuralgia, 
 phlegmasia dolens, and genital fistuhe, while local exam- 
 ination will reveal wide extension to the adjacent parts. 
 Successive attacks of subacute unumia may co-exist with 
 these, or the urremia becoming chronic, the patient 
 gradually sinks into a semi-comatose condition, and 
 quietly dies. Peritonitis, by extension or perforation, 
 may bring about speedy termination, or septicemia, 
 especially in neglected cases, may alone be the immediate 
 cause of death. 
 
 Diagnosis. In this disease, perhaps mon* than in any 
 other, the necessity for early diagnosis is imperative to be 
 of much benefit. The early stage can never be dijignosi'd 
 with certainty without microscopical examiuRtion of an 
 
DISEASES OP THE UTERUS— MALIGNANT NEOPLASMS. 281 
 
 excised piece from the suspected part. As already stated, 
 when speaking of endocervicitis, it may resemble follicular 
 erosion, but it differs from it in having scmewliKt elevated 
 and indurated edges. The :'aw surface in both conditions 
 may bleed with equal readiness, but if papillary projec- 
 tions are already present, in cancer they break down 
 much more readily. It may be mistaken for a submucous 
 fibro-myoma protruding from the os, but if carefully 
 examined, a healthy ring of cervical tissue will be found 
 encircling the neoplasm. 
 
 When the disease begins in the cervical canal, early 
 diagnosis may be extremely difficult. It may have made 
 considerable progress, and yet there may be nothing 
 abnormal in appearance. The chief clinical distinction 
 between beginning cancer and endocervicitis will be found 
 in the fact that the discharge in the latter condition 
 always retains its mucous consistency, while in cancer the 
 discharge is mostly of a watery consistency, and has an 
 offensive odor. A nodule may be suspected to be malig- 
 naTit if it is hard and protuberant, the exterior of a bluish 
 color, and the patient over thirty five years of age. 
 Advanced stages of cancer of any part of the cervix are 
 readily diagnosed by the symptoms already mentioned, 
 but in such instances it is usually impossible to recognize 
 from what part of the cervix it originated. 
 
 The proijuosis is not very good, even with operative 
 interference. Could the disease be discovered in its 
 earliest stages, total extirpation might give better results 
 than they usually do. When the pelvic connective tissue 
 or lymphatics are invaded, or the entire thickness of the 
 cervix involved, a p' rmanent cure cannot be held out. 
 
 Treatment. Treatment of cancer may be divided into 
 railirdl and jHiUiative. 
 
 Radical. Radical operation, to be successful, pre- 
 supposes conditions which will allow of the total removal 
 of all disease. There must be complete absence of exten- 
 
282 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 sion to any surrounding organ or gland, to tho ijoritonotim, 
 broad ligament, bladder, rectum or vagina. The utoruH 
 must bo freely movable nnd unassociated with severe 
 pelvic pains. When these conditions exist operation 
 should at once be proceeded with. 
 
 Hij/h (imput<itioti of the cervix by one of the methods 
 described when speaking ol liypertrophy of the cervix is 
 recommended, and has been frequently performed, but the 
 operation is not upheld now as being the best, because 
 independent cancerous nodules in the body of the uterus 
 have been observed, and second, the operation, when 
 properly performed, is just as difficult and nearly as 
 serious as complete extirpation. 
 
 Vaginal hysterectomy. Colpo-hysterectomy. The 
 patient is placed in the dorsal position, and the knees kept 
 apart and the thighs flexed on the pelvis by means of 
 Clover's crutch. A large Edebohls' speculum is inserted 
 into the vagina, and by means of scissors and a sharp 
 curette, exuberant tissue is cut or scraped away. The 
 uterus being next curetted, and the interior packed with 
 a little iodoform gauze, the cervix is closed with a few 
 sutures. After again thoroughly cleansing the vagina 
 and fornices, a strong vulsellum is introduced into the 
 lips of the cervix and the uferus drawn down. Except 
 when the cervix can be brought outside the vulva, lateral 
 retraction will be of advantage to give the operator more 
 room and light. A pair of scissors is made to cut through 
 the mucous membrane around the cervix, at a distance 
 well clear of the disease. By means of the finger, or by 
 the handle of a scalpel, or by closed blunt-pointed scissors, 
 the mucous membrane is elevated from the cervix all 
 around, the uterus being drawn forward and backward to 
 facilitate the manipulations. In front great care mus' be 
 observed not to open into the bladder, and if there is any 
 doubt, the introduction of a sound through the urethra 
 will serve as an excellent guide. When the mucous 
 
DISEASES OF THE UTERUS — MALIGNANT NEOPLASMS. 283 
 
 mombrnno has been rnisod from the cervix as high ns the 
 pcritonoum, that mombrano is perforated behind and in 
 front, and a few layers of gauze, secured at one end by 
 means of a ligature, pushed into Douglas' cul-de-sac, to 
 keep the bowels out of the way. The uterus is next well 
 drawn down and the division and closure of the blood 
 vessels of the broad ligament proceeded with. For this 
 purpose a variety of plans have been devised, but the 
 
 Fig. go — Vaj'inal hysterectomy by ligature. 
 
 principal ones may be described under two headings, by 
 h'gfitii7'es, and by chimps. 
 
 Bji lujatnrc. The material for ligature may bo either 
 good reliable catgut or silk. A pedicle needle armed with 
 the ligature, and guided by the index finger, is introduced 
 behind the broad ligament, close to the uterus, and passed 
 through and made to emerge in front of the ligament as 
 high ui) above the uterine artery as possible. Another 
 ligature is oassed in the same way on the opposite .'•ide, 
 and, after being carefully tied, those portions of the broad 
 
284 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 ligaments included within the ligatures are divided. The 
 uterus may now be pulled still farther down. If the first 
 ligatures have not secured enough of the broad ligaments 
 to bring the body of the uterus fairly into view, others may 
 be placed on each side higher up. The uterus being now 
 drawn weJl down, the tubes and ovaries may be felt. A 
 ligature is passed over the infundibulo-pelvic ligament, 
 and after being carefully tied, is divided. The corre- 
 sponding ligament on the other side will then be very 
 readily ligated, and, after division, the uterus will be free. 
 
 If there is much difficulty in bringing the tubes and 
 ovaries into reach they may be left behind, the last liga- 
 ture passing over the tubes, as they lie in the free margins 
 of the broad ligaments. If the tops of the broad ligaments 
 are beyond easy reach of the finger, or the uterus consider- 
 ably enlarged, inversion of the fundus, either in front, or 
 behind through the opening in Douglas' cul-de-sac, will 
 always bring them within reach. After removal of the 
 uterus the gauze packing is withdrawn, and steps taken 
 for the management of the vaginal wound, for which 
 various methods have been adopted. The broad ligament 
 stumps may be drawn down with bullet forceps into the 
 vagina, and a full-curved needle introduced through them 
 on either side, entering anteriorly through the vagino- 
 peritoneal margin, and emerging posteriorly in the same 
 manner, and the ligature tied. The opening in the 
 vaginal wall is now closed with a few sutures. Some 
 surgeons recommend that simply the peritoneum should 
 be sutured to tiie vagina, others that the vagina alone 
 should be sutured, while others leave all the structures to 
 fall into apposition and unite as best they can. The 
 vagina may now be packed with iodoform gauze. When 
 the vaginal wound has been left open, a few strips of gauze 
 should be put in the slit, particularly when drainage is 
 necessary. 
 
DISEASES OF THE UTERUS — MALIGNANT NEOPLASMS. 285 
 
 IVic clamp method. The first steps in this method are 
 the same as have already been described. The peritoneum 
 is opened in front and behind, and if it be convenient to 
 do so at this stage of the operation, may be attached to 
 the margins of the vagina. A clamp is now placed on the 
 base of the broad ligaments, one on either side, and the 
 ligaments divided close to the uterus. The uterus is now 
 drawn lower down, and the remaining part of the ligaments 
 
 Fig. 91.— Vaginal hysterectomy with clamps. 
 
 included in a second pair of clamps, and also divided. 
 The handles of the forceps are securely tied to prevent 
 them from springing open, and wrapped with gauze, after 
 which the vagina is lightly packed as before. The clamps 
 are allowed to remain in place for thirty six to forty eight 
 hours, after which they may be removed. Instead of 
 incising the mucous membrane around the cervix, the 
 thormo-cautery is sometimes used, and as the uterus is 
 
286 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 being separated from the bladder, the tip of tbo caut(^ry 
 knife is kept almost constantly in close contact with the 
 uterus. By this method the operation practically becomes 
 a bloodless one. 
 
 Abdominal hysterectomy is at times performed for 
 cancer of the cervix, the advantage claimed for it being 
 that more of the broad ligament can be removed, and by 
 this means it is possible to get farther away from the 
 disease. A combination of the two methods, vagino- 
 abdominal hysterectomy, is also now performed, the upper 
 portion of the uterus being freed by abdominal incision, 
 and the lower portion through the vagina. 
 
 Sacrnl hysterectomy. Kraske's operation for cancer 
 of the rectum has been adapted to the removal of a 
 cancerous uterus, but the operation has not received much, 
 if any encouragement. 
 
 Palliative treatment. When the disease has pro- 
 gressed to such an extent as to make radical treatment 
 inadvisable, only palliative treatment is left. Among the 
 various remedies and forms of treatment, curettage, with 
 subsequent cauterization by means of the thermo-cautery, 
 is one of the best. Another efficient treatment consists in 
 packing the crater formed after curettage with a fifty-per- 
 cent solution of chloride of zinc, the vagina and bladder 
 being protected by gauze moistened with a solution of 
 bicarbonate of soda. If there is a tendency to hemorrhage 
 after the removal of the slough, or practically at any time, 
 it may be checked by vaginal tamponade, either alone or 
 combined with some styptic, such as perchloride of iron. 
 Local antiseptic treatment must be constantly kept up. 
 Injection of a one-per-cent solution of creolin is valuable 
 both as a heemostatic and antiseptic. Peroxide of hydrogen, 
 or a weak solution of permanganate of potash, has a 
 decided cleansing and deodorizing effect. Equal parts of 
 iodoform and charcoal will relieve pain and counteract the 
 objectionable odor. Suppositories made from chloral and 
 
DISEASES OP THE UTERUS— MALIGNANT NEOPLASMS. 287 
 
 tannin (an. gr. xv.) will relievo pain, lessen hemorrhage, 
 and counteract the offensive odor. 
 
 Narcotics will invariably become necessary at some 
 time during the course of the malady, and it has been 
 claimed that when opium is freely used, the progress of 
 the disease is to some extent retarded. So far no drug 
 has been found that will cure cancer, although from time 
 to time new specifics have been praised. Condurango 
 bark, chian turpentine, methyl blue, have all enjoyed a 
 short lived celebrity. Not much more can be done than 
 to sustain the general health as far as possible, and treat 
 complications ns they arise. 
 
 CANCER OF THE CORPUS UTERI. 
 
 Modern means of investigation have shown that 
 primary cancer of the body of the uterus is not so rare as 
 was once thought. Two varieties may be distinguished, 
 epithclionui and adeno-carcinoma or malignant adenoma. 
 
 Epithelioma occurs as a diffuse growth of villi through- 
 out the whole uterine cavity, and consists of an atypical 
 development of epithelial cells of different sizes. It has 
 little tendency to involve the mucous membrane of the 
 cervix, but the uterine wall, little by little, is eroded and 
 destroyed, and the interior of the uterus converted into 
 an ulcerated cavity. 
 
 Adeno-carcinoma occurs as an isolated fungoid growth 
 with a large or small base, and at times has the form of a 
 polypus. Histologically the tumors are corajjosed of 
 anastomosing tubules filled with cells. The first layer of 
 cells implanted on the wall is regularly cylindrical, and 
 the successive layers are formed by polyhedral cells which 
 are, at times, of the pavement variety. The interior of 
 tiie mass also contains alveoli, lined with one or two 
 layers of epithelial cells, as well as cavities containing 
 mucous and free cells. At a later period, in both varieties, 
 metastatic nodules form in various parts of the parenchyma, 
 
288 
 
 MEDICAL AND SURGICAL GYNJICOLOGY. 
 
 and even under the peritoneum, forming protective ad- 
 hesions and metastatic noduh^s there. Frequently tht>se 
 metastatic nodules are found superficially in the vagina, 
 and deeply in the ovaries and tubes. 
 
 Symptoms. Hemorrhage is the primary symptom, and, 
 as in cancer of the cervix, it is usually accompanied by a 
 serous discharge, of a reddish color and disagreeable odor, 
 and with this there is often a discharge of small shreds of 
 tissue from the broken down parts of the fungosities. 
 Symptoms of uterine inflammation are often noticeable, 
 
 Fig. 92. — Medullary cancer of body of uterus. 
 
 but, as the disease becomes more advanced, the pain takes 
 on a paroxysmal character which is remarkable and also 
 pathognomonic. These crises have none of the character- 
 istics of colic, and are peculiar from their appearance, at 
 almost regular hours, once or twice a day. Bimanual 
 examination shows the organ to be increased in volume. 
 It remains movable for a long time, but finally becomes 
 imprisoned by adhesions. The cervix is found free from 
 disease, but often is much softened a:.id partly open. 
 
DISEASES OF THE UTERUS — MALIGNANT NEOPLASMS. 289 
 
 The sound rovonls nii increase in the capacity of the 
 uterus, and the presence of irreguhir masses. The general 
 health fails as the neoplasm develops and terminates in 
 cachexia. 
 
 DifUfiiosis. In the early stages this may be very 
 difficult. The hemorrhage, the serous dischar?^e, the in- 
 crease in the volume of the uterus, itnd the results of 
 intra-uterine exploration, constitute the clinical elements 
 of the case, while the microscopical examination of por- 
 tions removed by the curette clearly differentiates between 
 cancer and metritis without malignant neoplasm, or be- 
 tween carcinoma and sarcoma. 
 
 Treatment. When seen sufficiently early the only treat- 
 ment is total eradication of the uterus by hysterectomy. 
 
 SARCOMA. 
 
 Sarcoma is a comparatively rare form of malignant 
 disease of the uterus. It may occur at any period of the 
 sexual life of the woman over twenty years of age, but is 
 most often fouad just before, or just after the menopause. 
 There are three well defired forms of sarcoma. 
 
 Fibro-sarcoma. This form occurs in tumors or 
 masses, and has a striking resemblance in growth and 
 structure to fibro-myomata. Like them they occur as 
 submucous, interstitial, or subserous tumors, and have 
 their origin also in the parenchyma of the uterus, but 
 instead of being limited by a loose capsule, it is, as a 
 distinctive characteristic, deeply rooted. The vast weight 
 of authority is in favor of the view that they are malignant 
 transformations or degenerations of the ordinary fibro- 
 myomata. Histologically they show a proliferation of 
 round, and in places fusiform cells, more or less replacing 
 the normal tissues of the uterine wall. When they have 
 a pedicle it is apt to be fibrous, intimating that it has 
 come from a degenerated fibro-muscular polypus. They 
 give rise sometimes to metastatic growths in distant parts 
 
2iK) MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 of the body, but show little tendency to disintegration or 
 trnnsformntion. Occasionnlly cystic degeneration takos 
 place, giving rise to cif^to-sarrom'i. 
 
 Diffuse sarcoma. SarcomH of the endoraetriu~n closely 
 resembles the typical form of carcinoma of the sau e 
 structure. The term is used to desigiiate a new growth 
 proceeding from the connective tissue of the uterine 
 mucous membrane, consisting mostly of small closely 
 packed round cells, though sometimes spindle-shaped, and 
 producing soft villous or lobulated tumors of an encepha- 
 loid aspect. The tissue does not break down as readily as 
 that of epithelioma, but is apt to fill the uterus and 
 present at the cervix. The uterine walls are gradually 
 invaded, and become a mere shell filled with the encepha- 
 loid mass. This form is found most frequently in young 
 women. 
 
 There is a rare variety, mah'tpuint (Iccichioma (sarcoma 
 uteri deciduo-cellulare). Many authorities dispute this 
 variety of sarcoma as a particular form, considering it 
 simply a mixed sarcoma. It is developed soon after 
 parturition or abortion in the placental remains or 
 decidua, and is composed of polymorphous decidual cells, 
 and giant cells embedded in connective tissue. 
 
 Sarcoma botryoides, or grape-like sarcoma (papillary 
 sarcoma of the cervix) is a variety which appears in the 
 c'?rvix, and as such is characterized by its grape-like form. 
 Clinically, it is extremely malignant. Tire mass is soft in 
 consistence, and grows to a large size, often filling the 
 vagina. The disease spreads along the mucous membrane 
 into the uterus, and to the vagina, and finally invades the 
 pelvic connective tissue and peritoneum. 
 
 Symptoms and course. All forms run a more rapid 
 course than the corresjionding carcinomata after the 
 symptoms first attract attention. Fibro-sarcoma gives 
 rise at first to the same symptoms as fibro-myoma, and it 
 is stated that when a tumor, previously existing as a fibro- 
 
DISEASES OP THE UTERUS— MALIGNANT NEOPLASMS. 29J 
 
 myoma, begir s to grow Rt th > me^iopnusc, it is uiulorgo- 
 iiig sarcomntouH trnasfonimtion. Wlioii post-climateric 
 growth occurs, two symptoms soon appear. One is jjain, 
 owing to tension or invasion of the peri-uterine connective 
 tissue, the other is marked deterioration in the general 
 ?'ealth. If the neoplasm has developed from a submucous 
 fibro-myoma, there will be severe hemorrhage, and pain 
 from the efforts of the uterus to expel the tumor. As it 
 advances in growth, in addition to occasional violent 
 hemorrhage, it may cause a sanious hydrorrhcua, and the 
 discharge will sooner or later take on an ott'ensive odor. 
 Owing to the intense anjemia, sapra^nia, and marasmus, 
 death is readily produced. Death may occur from peri- 
 tonitis, intestinal obstruction, or from pressure on the 
 ureters. In the diffuse form the symptoms are not dis- 
 tinguishable from carcinoma affecting the same structures. 
 
 Diagnosis. With the exception of the rare form, 
 sarcoma botryoides, it cannot positively be diagnosed 
 without microscopical examination. The clinical symp- 
 toms must be carefully observed, and in this there are two 
 points desiTving special attention; first, the rapid growth, 
 at or about the menopause, of a tumor previously known 
 to exist; and second, a more marked ansemia and deterior- 
 ation of health than is ever found associated with the 
 same stage of growth of a benign tumor. 
 
 The treatment is, as in other forms of malignant 
 neoplasms, palliative or radical. If the uterus is movable, 
 and there is no metastasis or invasion of the vagina, total 
 extirpation of the uterus is at once to be undertaken. 
 
292 MEDICAL AND SURGICAL OYN.ECOLOOY. 
 
 CHAl'TER XXVI. 
 
 DISEASES OF THE FALLOPIAN lUBES. 
 
 Malformations. Tlu^ ubes show a numbor of devolop- 
 mentai anomalies, but thoy arc of little importance except 
 in the study of the etiology of tubal gestation. Accessory 
 fimbriated extremities are not uncommon. There may be 
 an accessory uterine orifice, or the whole duct of the tube 
 may be duplicated. In connection with imperfect develop- 
 ment of the whole sexual apparatus, the tubes may also 
 be non-developed; they may possess an abnormally small 
 calibre; they may be without any lumen; or they may bo 
 entirely absent. On the other hand, the tubes may show 
 an abnormally great development, with corresponding 
 patency of the canals. They may be congenitally displaced 
 backward and downward into Douglas' pouch, or they 
 may be wound in a spiral, or abnormally contorted. 
 
 SALPINGITIS AND ITS COMPLICATIONS. 
 
 The important position taken by inflammation of the 
 uterine appendages has but recently been generally 
 admitted. To thoroughly understand the close association 
 of inflammation of one organ with that of the other, the 
 common embryonic origin of the uterus and tubes, and 
 the close association of the ovaries, must be borne in 
 mind. The various coats of the tubes and ovaries are 
 continuous with each other, a fact which explains the 
 possibility of ascending salpingitis following endometritis, 
 just as ascending pyelitis may follow chronic cystitis. 
 The ovary, which is connected with the tube by the tubo- 
 ovarian ligament, and almost in direct contact with the 
 ampulla, may also be easily infected by continuity. In 
 addition, these organs are intimately bound together by 
 important vascular and lymphatic vessels, so it may be 
 said that there is scarcely ever a salpingitis unaccompanied 
 by ovaritis, or an ovaritis uncomplicated by salpingitis. 
 
r EASES OF THE FALLOPIAN TUBES. 
 
 293 
 
 Non-cystic salpingitis. 
 
 Cystic snlijingitis. 
 
 Salpingitis and its results may be studied from n 
 clinicni nn<l anntomicnl standpoinl. under the following 
 classification : — 
 
 (<i. Acute catarrhal. 
 h. Acute purulent. 
 ('. Chronic parencliymatous. 
 ( Pachysalpingitis. ) 
 
 (a. Hydrosalpinx. 
 
 -. h. Pyosalpinx. 
 
 {('. Hematosalpinx. 
 
 Acute catarrhal and purulent salpingitis. The chief 
 causes of salpingitis are intlammatory conditions of the 
 uteriis, gonorrlueal infection, puerperal infection following 
 parturition or abortion, and contamination from surgical 
 exploration or interference. 
 
 P(ifli<)J<>(/i/. In the acute caiarrhal form the tube is 
 swollen cylindrically, from about the size of the little finger 
 to that of the thumb, and owing to its lower border being 
 attached to the broad ligament, becomes more tortuous. 
 The lesions are especially marked in the mucous coat, 
 being thickened, infiltrated with round ct^Us, and moistened 
 with abundant mucous secretion. The normal folds are 
 swollen, and covered with lateral newly formed vegeta- 
 tions. In places they are agglutinated, enclosing spaces 
 between them, giving the appearance of glandular forma- 
 tion. The epithelial cells, as a rule, maintain their 
 integrity, and the fibro-muscular coat is but slightly 
 affected, there being only a hyperplasia of its substance. 
 The fimbriated extremity is at first jjatulous, but later the 
 fimbrire become contracted and folded up. The uterine 
 ostium generally remains patulous, through which the 
 excess of mucous is discharged. In some cases a few 
 drops of mucous escape through an uncljsed fimbriated 
 extremity, giving rise to a slight localized peritonitis. 
 
 In piirnhmt sdlpini/i'tis there will be evidences of 
 extensive inflammation. The tubes are swollen, twisted 
 
294 MEDICAL AND SURGICAL GYNJICOLOOY. 
 
 and tortuous, and tho fimbria so ngglutinatod as to close 
 tho abdominal orifice. On section it is found to be filled 
 witli a creamy pus, the cavity often resembling a string of 
 beads owing to contraction. The pus can or.sily bo 
 evacuated through the uterine cavity, as the ostium 
 internum is not occluded like the ostium abdominale. 
 The mucous membrane is of a grayish tint, and under the 
 microscope a transverse section shows thick reduplications, 
 forming a system of primary and secondary folds enclosing 
 irregular cavities that look like glands. This thickening is 
 duo to the infiltration of migratory cells in the connective 
 tissue. The ciliated cells are destroyed, and the epithelial 
 cells are changed in shape. The whole thickness of tho 
 wall is also infiltrated with round migratory cells, and the 
 blood vessels are dilated. In the beginning the disease is 
 usually confined to one side, but if left unchecked, is apt 
 to affect the other. Usually some exudate appears on the 
 serous surface, forming adhesions with tho surrounding 
 surfaces, but the greatest amount of localized peritonitis 
 and adhesion is set up by an occasional exudation of pus 
 from the abdominal end, which, when frequently repeated, 
 has the effect of agglutinating the pelvic organs, omentum, 
 and intestines into a matted mass. Accumulations of pus 
 or serum b(^tween the adhesions are occasionally found, 
 sometimes displacing the uterus laterally or forward. 
 
 Iiif('rstiti<(l sal])ifi(/itis represents an advanced stage of 
 the purulent form. Both tubes will be found involved, 
 and the lesions, instead of being limited for the most part 
 to the mucous membrane, include the whole thickness of 
 the walls, so that they become thickened, hardened, and 
 purplish in color. Sometimes the induration is general; 
 at times it is more marked in places, giving the tube a 
 peculiar nodular appearance. The mucous membrane is 
 dark blue in color; the villi are enlarged, united, and in 
 Ijart destroyed by small celled infiltration. False glands 
 and cystic spaces are thus produced at some distance 
 
DISEASES OF THE FALLOl'IAN TUBES. 
 
 295 
 
 below the surface. The externnl orifice is nlwnys obliter- 
 fttod, but the uterine orifice in more or h^ss pervious. The 
 mesosnipinx may be expanded by the enhirged tube, or it 
 mny be folded up by adhesions, or infiltrated by infiain- 
 matory products. The ovary, which often preserves its 
 integrity in the catarrhal form, is usually affected. It 
 is generally displaced, 
 fixed by adhesions in 
 DoughiH' pouch, or to 
 the sides of the pelvis, 
 or it may suppurate 
 independent of t h e 
 tube. The peritoneal 
 adhesions, which may 
 also involve the omen- 
 tum and intestines, are 
 dense and strong, and 
 are sometimes so firm 
 that they cannot be 
 broken up without 
 
 laceration of the peritoneal surfaces, or even of the walls 
 of the viscera. Organized bands may extend between the 
 surfaces in all directions, so as to make it difficult at times 
 to determine the relations of the parts after the abdomen 
 has been opened. 
 
 . Symptoms. As acute salpingitis usually occurs in 
 patients already exhibiting symptoms of endometritis, it 
 is difficult to decide with precision to which lesion the 
 symptoms are due. Pain situated in the neighborhood of 
 the appendage, or in the lumbar region, and radiating 
 upward to the epigastrium and downward to the thigh, is 
 generally present. A bimanual examination elicits tender- 
 ness and fulness on one side of the uterus, and some pain 
 when that organ is moved or displaced by the fingf r. 
 Leucorrhoea is present to a greater or loss extent, and 
 when the menstrual flow appears it is usually very pro- 
 
 FlG. 93. — Salpingitis with pelvic peritonitis and ad- 
 hesions posterior to the uterus. 
 
2% MEDICAL, AND SURGICAL OYN^EC'^UHIY. 
 
 fuHo. Gonrrnl conHtitutioiinl HymptorriH mny npprnr, Huch 
 RH n fooling of mnhiiHo, noumlgio pniiis Hcnttorod ovor tho 
 body, and n Blight rino of tompornturo and pulso. Shoulf. 
 muooiiH oscnpo tiirougli tlio outor opening, tlu^ro will bo nn 
 oxncorbntion of tho HymptoniH, charactiTizod by incroawc^d 
 pain in the iliac region, local tympanites, nausea and 
 perhaps vomiting, and other symptoms of a mild form of 
 local peritonitis. 
 
 When the salpingitis is of the purulent form the 
 symptoms may be similar to those just described, but they 
 are likely to be morci pronounced in character, and slower 
 in subsiding. Should gonorrluBal pus make its escape 
 through the outer ostium, the peritonitis may not be much 
 more severe than that already described, but when the 
 case is one of mixed infection, an extensive pelvic i)eri- 
 tonitis will be set up, accompanied by great tympanites, 
 high temperature, rapid pulse, extensive pelvic pain and 
 tenderness, and as a result, there will be an abundant 
 peritoneal and cellular effusion which becomes hard and 
 solid, like plaster of Paris, and which may partly or 
 entirely fill the pelvis. The symptoms may last for a few 
 days, and after confinement to bed for a few weeks, the 
 patient may, as far as her symptoms are concerned, entirely 
 recover for a few weeks, months, or even years. Sooner 
 or later, however, perhaps after some unusual exertion or 
 exposure to cold, more particularly at the menstrual period, 
 a recurrent attack of peritonitis will make its appearance 
 with the same suddenness as before. In many cases the 
 symptoms do not subside entirely, but remain in a semi- 
 quiescent state, the patient suffering more or less from the 
 milder form of symptoms in the intervals. When the 
 attack results from direct infection during abortion or 
 operative procedure, the symptoms of a general ii ''ection 
 will probably predominate, indicated by chills, high pulse, 
 exaceroation of fever, the temperature rising and falling 
 three or four degrees once or twice daily, being highest in 
 
. DISEASES OF THE FALLOPIAN TUBES. 2V)7 
 
 most cases in tho afternoon or enrly evening. Other 
 symptoniH of a general peritonitiH m/iy rapidly follow, 
 8U(rli as abdominal diHtt*nHion, labored riiHpiration, a wt^ak 
 thready pulwe, piirniHti^nt vomiting, and cold clammy 
 perspiration, all indicating that death is near. 
 
 A vaginal <\xamination will reveal an enlarged and 
 tend uterus surrounded by highly sensitive infiltrated 
 tisE'i' % in which a hard mass may or may not be found. 
 In severe cases abdominal palpation may reveal a tender 
 exudate extending from the enlarged uterus, but when tho 
 symptoms have been mild, there may be nothing but deep- 
 seated tenderness. 
 
 The symptoms of interstitial salpingitis are those of 
 an ailment which has extended over a considerable length 
 of time, with more or less severe attacks of pelvic inflam- 
 mation occurring at varying intervals. There may be a 
 history of but a single attack of pelvic peritonitis, but 
 that is exceedingly rare. There will more likely be a 
 history of recurrent attacks, with intervals of good health, 
 or of semi-invalidism. during wliich the patient is in- 
 capacitated by pain or discomfort from the ordinary duties 
 of life. Between the attacks the symptoms of endometritis 
 are seldom absent. There will likely bo a burning pain in 
 one or both iliac regions, radiating into the lumbar, gluteal 
 or sciatic regions. Painful micturition and defecation, 
 dysmenorrhoea and intermitteni or constant leucor- 
 rho3a are often present. In the earlier stage, when pus is 
 present, there is apt to be an afternoon rise of temperature, 
 possibly a degree or two, but after the disease has lasted 
 for a length of time, and septic influences disappear, the 
 temperature will probably remain normal throughout the 
 day. Along with these symptoms there may be those of 
 a general nervous disturbance, such as nausea, indigestion, 
 neurasthenia and hysteria. A bimanual examination will 
 reveal an enlarged, hard, tender mass behind or beside 
 the uterus, with more or less immobility of that organ, or 
 
298 MEDICAL AND SURGICAL GYNJICOLOGY. 
 
 the uterus may be fixed in one side of the pelvis by bands 
 of adhesions, and surrounded by a thickened and hard 
 mass. The discharge issuing from the cervix may be 
 thick tenacious mucous or muco-pus. Tlie uterus itself 
 will bo found in a condition of subinvolution, or of chronic 
 metritis. 
 
 Prognosis. Catarrhal salpingitis frer^uently ends in 
 restoration of the tubes to a practically normal condition. 
 When the disease, however, has existed once, it is apt to be 
 reproduced by the accompanying endometritis; or a puru- 
 lent salpingitis may be established. Purulent salpingitis 
 may endanger life, owing to the eocape of pus through the 
 ostium abdominale and the consequent local or general 
 peritonitis or abscess formation. There is, as a rule, 
 sterility, or a strong tendency to the occurrence of 
 ectopic gestation. Interstitial salpingitis usually con- 
 demns the patient to more or less chronic invalidism. In 
 some cases it involves all the dangers of pyosalpinx, while 
 in others there may bo a gradual improvement of both the 
 local and general symptoms, a recovery from septic con- 
 ditions, and a final restoration to comparative good health. 
 
 Treatment. As the disease is asually an extension of 
 endometritis; much may be done to prevent its occurrence. 
 Acute metritis following labor, abortion, or operation, 
 should, as soon as dip^nosed, be treated on thoroughly 
 active and antiseptic principles, and the same advice is 
 applicable in cases of gonorrhoeal infection. It may be 
 necessary to curette the uterus, after which it may be 
 touched over with strong carbolic acid, and the antiseptic 
 treatment subsequently k» pt up by vaginal or intra-uterine 
 douches. The treatment of catarrhal salping' tis is identical 
 with that of endometritis. Absolute rest in bed is neces- 
 sary, and measures taken to relieve congestion, and favor 
 drainage of the uterus and tubes. Hot fomentations 
 should be continually applied over the abdomen and vulva, 
 and a hot water bag beneath the lumbar region. A sharp 
 
DISEASES OF THE FALLOPIAN TUBES. 299 
 
 saline cnthnrtic, such as sulphate of magnesia or soda, 
 Rocholle salts or phosphate of soda, should be at once 
 administered, and repeated suC jiently often to keep the 
 bowels relaxed, and in the intervals a mild febrifuge 
 mixture may be prescribed. If much pain is present it 
 may be relieved by phenacetine, Dover's powder, or small 
 doses of morphine, or by the introduction of an anodyne 
 into the vagina or rectum by means of a suppository. 
 Warm vaginal douches should be administered every four 
 to six hours, while the patient lies on her back upon a bed- 
 bath. As the acute stages are subsiding the fomentations 
 may be withdrawn, and the lower abdomen painted over 
 with tincture of iodine. The douches are, however, to be 
 continued, the temperature of the water being gradually 
 elevated to the maximum degree which the patient can 
 endure without much discomfort. 
 
 The same treatment is applicable to purulent salpingitis 
 at the outset, with the addition of intra-uterine douches 
 every eight to twelve hours, if the os will permit the 
 entrance of the instrument. In case that it will not, it may 
 be advisable to dilate the cervix for that purpose. When 
 severe peritoneal symptoms are present, vaginal and intra- 
 uterine douches, and all manipulations likely to interfere 
 with absolute rest, should be avoided until they have 
 subsided. If there is dee'ded rise of temperature, especi- 
 ally when intermittent, quinine, in five grain capsules, 
 will act better than any other fe^ ifuge treatment. After 
 the subsidence of the symptoms of an attack, prophylatic 
 treatment should be continued, and every effort made to 
 prevent the recurrence. For this purpose the patient 
 should avoid all worry, excitement, fatigue, or over-work, 
 resting, if possible, for a few hours every day. Antiseptic 
 vaginal douches and mild counter-irritation over the 
 abdomen should be continued, and during the menstrual 
 period she should remain in bed. Drainage through the 
 uterus should be encouraged and kept up, and for this 
 
300 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 purpose the cervix should be dilated once or twice a week, 
 and the uterine cavity touched over with some mild but 
 efficient antise^ tic, such as a twenty-five-per-cent solution 
 of ichthyol in glycerine. After each treatment the vaginal 
 vault may be painted with tincture of iodine, a tampon of 
 cotton aaturated with boro-glyceride placed against the 
 cervix, and the vagina lightly packed with gauze. 
 
 When the case has become chronic, and there is but 
 little tenderness, and no signs of pus in the pelvis, 
 electricity and pelvic massage have been praised, as 
 favoring the absorption of the exudate, but in view of the 
 difficulty there exists in making a diagnosis, such treat- 
 ment must of necessity be surrounded by great dangers. 
 
 If all therapeutic measures fail, after a sufficient delay 
 recourse must be had to the radical operation of salpingo- 
 oophorectomy. It is preferable to delay operation until 
 the subsidence of an acute attack, but when the severity 
 of the symptoms are such as to lead to the conviction that 
 a purulent salpingitis is immediately endangering life, no 
 delay should be made, but radical measures resorted to at 
 once, for the removal of the adnexa and possibly of the 
 uterus. Salpingo-oophorectomy is also indicated in inter- 
 stitial salpingitis, if the patient suffers much pain, and 
 has repeated attacks of pelvic peritonitis. 
 
 Salpingo-oophorectomy. The appendages may be 
 removed through the abdominal walls or through the 
 vagina. 
 
 1. Abdominal sdlpingo-oophorectomy . The abdominal 
 incision is made in the median line sufficiently large to 
 allow the entrance of two fingers. The first and middle 
 fingers are introduced into the abdominal cavity, the 
 omentum and intestines pushed up, and the fundus of the 
 uterus sought for. Passing the fingers outward along the 
 tube to the ovary, they are both lifted up between the fingers 
 through the abdominal wound. If there are adhesions 
 they are cautiously separated, relying on the sense of 
 

 DISEASES OF THE FALLOPIAN TUBES. 301 
 
 touch nlone. If the points of adhesions are difficult to 
 overcome, they may be lifted into the wound and separated 
 there, or it may be necessary to enlarge the incision, so as 
 to make the whole pelvis accessible to the eyes and hands. 
 When the tube and ovary are lifted up, a pedicle needle, 
 threaded with a strong silk or catgut ligature, is pushed 
 from the front backward through the broad ligament, a 
 half to three quarters of an inch under the ovary. After 
 removal of the needle, the ligature is brought up over the 
 tube, close to the uterus, and tied tightly, after which the 
 endp passed below the ovary, and sufficiently far away 
 fron ,o allow for u pedicl , and again tied tightly. By 
 this means the tube, ovary, and the included broad liga- 
 ment are tied off, and may now be removed with a pair of 
 scissors, taking care to take away all of the ovary, and as 
 much as possible of the tube, while on the other hand 
 sufficient pedicle should be left to prevent the ligature 
 from slipping. After carefully walohing the stump to 
 make certain that the vessels are securely tied, the surface 
 may be smeared with a little iodoform, or aristol, the liga- 
 ture cut short, and the pedicle allowed to sink down into 
 its normal jjosition. 
 
 As to the treatment of the appendages of the other side, 
 there is much difference of opinion ; some authorities 
 recommend their removal even if they are healthy, because 
 they will very likely become affected later, while others 
 recommend that an effort should be made to save them, 
 even if found to be slightly diseased, particularly where 
 offspring is much desired. If both appendages must be 
 removed, it is rJmost as well to remove the uterus too. 
 This organ is often the source of the infection, and besides, 
 after the removal of the appendages it is useless, and may 
 be the cause or source of a new infection. 
 
 Besults. ^n a very large percentage the operation 
 brings on the menopause at once, or after a few months. 
 When menstruatio.i continues, it may be due to the in- 
 
302 MEDICAL AND SURGICAL GYNJICOLOGY. 
 
 complete removal of the appendages, to irritation of the 
 stump, to disease of the uterus, or to the law of " persis- 
 tence of habit." As a rule there is a discharge of blood 
 for several days following operation, which is accounted 
 for by the congestion caused by the ligatures. The sexual 
 appetite may remain unchanged, increased, diminished, or 
 may disappear altogether. In a considerable number of 
 cases melancholia has developed. Even if the mental 
 disturbance does not go so far as insanity, despondency 
 and irritability are qui(;e frequently observed. 
 
 Vaginal salpingo-oophorectomy presents the advan- 
 tage that there is less shock, and less risk of causing a 
 hernia, but it has the disadvantage that the field of 
 operation is narrow and deep seated. When the diagnosis 
 is uncertain, and when there are adhesions to intestine or 
 omentum, it is much more difficult to cope with these 
 difficulties through the vaginal route than by abdominal 
 incision. 
 
 The vagina is opened by anterior or posterior colpo- 
 tomy, or by both, and if more room is necessary, an 
 incision in the median line may be carried from the 
 posterior transverse incision as far down as the bottom of 
 Douglas' pouch. The fingers are gradually worked up 
 until they pass through the peritoneum. Adhesions may 
 be now carefully broken up, after which the appendages 
 can be brought down and ligated. The vaginal wound 
 may be ligated in cases where there has been no local 
 infection, otherwise it is best to lightly fill the wound with 
 iodoform gauze, and subsequently the vagina. 
 
 Pyosalpinx signifies an accumulation of pus in a 
 closed or cystic Fallopian tube. It is merely a tube, the 
 walls of which show interstitial inflammation, with the 
 abdominal opening obliterated by agglutination and firm 
 adhesions of the fimbriae, and probably the uterine opening 
 also obliterated by inflammatory thickening, or by torsion 
 of the tube. The closure of the openings permits of the 
 
DISEASES OP THE FALLOPIAN TUBES. 308 
 
 retention of secretions and exudations within the tube, 
 and, as a result, it undergoes enlargement and distension 
 from the presence of its contents. The greatei enlarge- 
 ments occur as the result of closure of both ends of the 
 tube, the lessor are found in conjunction with a free 
 uterine end, the contents of the tube having some oppor- 
 tunity for escape into the uterus. The escape is either a 
 constant leakage, or an intermittent discharge, brought on 
 by direct contraction of the tube, or by indirect pressure. 
 
 Pyosalpinx is generally unilateral, but may be bilateral. 
 In the commonest form there is a general enlargement 
 of the tube, club-shaped at the outer end, and tapering 
 gradually towards the uterus, or more or less convoluted. 
 The diameter of such tubes may reacli an inch or more. 
 When there is an absence of constrictions, it may assume 
 the appearance of a pear-shaped cyst, and attain the size 
 of a normal uterus; rarely it may reach the dimensions of 
 a foetal head. The pus contained in the sac is often 
 mixed with blood, serum, or mucous, which accounts for 
 such collection not presenting the active tendencies of 
 collections of pure pus witnessed elsewhere. Collections 
 of pus in a tube will often remain relatively quiescent for 
 considerable periods of time, and may suffer partial 
 absorption and inspissation, appearing ultimately as a 
 pultaceous mass. The tendency, however, is for escape, 
 the direction being most often along the canal to the 
 uterus. Next in frequency, it tends to escape through 
 the abdominal end of the tube, and least frequently by a 
 combination of stretching and degeneration an opening 
 may be made througa the tube wall. 
 
 When the contents escape through the uterus, the 
 tendency of the tube is to refill, and thus alternately 
 emptying and refilling, the condition may exist for a long 
 time, either ending in atrophy of the tube, or in permanent 
 closure and the formation of a complete pus sac. Leakage 
 from the abdominal end is not uncommon, each escape 
 
304 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 being nccompnnied and followed, ns has already been 
 stated, by the phenomena of local peritonitis proportionate 
 to the amount and specific virulence of the fluid. 
 Leakage through the wall of the tube is less common, but 
 should it occur at the upper and posterior surface, the 
 favorite situation, there would be discharge of the tube 
 contents into the general peritoneal cavity, accompanied 
 by all the dangers which pertain to such an accident. 
 The opening may occur on the under surface of the tube, 
 between the layers of the broad ligament, through which 
 the pus reaches the subperitoneal cellular tissue, where 
 its further incapsulation is largely provided for. Fortu- 
 nately most cases of pyosalpinx beget such an amount of 
 local peritonitis about them as will ensure strong pro- 
 tecting peritoneal adhesions, and the occasional leakages 
 only add to, and extend the adhesions, so that even though 
 secondary foci of pus develop outside the tube, they are 
 again held in check. It is in this way that pelvic abscesses 
 are formed, and the further consideration of pus collections, 
 originating in pyosalpinx, will be considered under that 
 heading. 
 
 Hydrosalpinx. Hydrosalpinx is a cystic enlargement 
 of the tube, in which the general outlines and dimensions 
 of the organ are in the main similar to those found in 
 pyosalpinx. It is usually an advanced stage of pyo- 
 salpinx, and represents a practical destruction of the tube, 
 The walls are attenuated and may be so thin in places as 
 to be translucent. The contents are serous, not puru- 
 lent, and in many cases as limpid as water. It is found as 
 a bilateral rather than a unilateral disease, and is rarely 
 without the association of strong well organized adhesions. 
 It is free from the aggressive action which characterizes 
 pyosalpinx. It tends rather to quiescence, sometimes to 
 intermittent discharges through the canal into the uterus, 
 and ultimately to absorption and general atrophy, more 
 particularly of the outer parts of the tubes. 
 
DISEASES OF THE FALLOPIAN TUBES. ilOo 
 
 Haematosalpinx. Liko pyosalpinx, lianiintoHnlpinx 
 Ims itH sont in tho ampulln, and hns similar dimoiisions 
 and form. Leaving aside that form already mentioned 
 when speaking of atresia of tho genital tract, there are 
 two chief varieties. 
 
 The first and most frequent is apoplexy of the tube, 
 a condition which may occur in the coarse of a catarrhal 
 inflammation, or during an irregular menstruation affected 
 by fatigue, cold, or pelvic or uterine congestion. The 
 tube is about the size of the middle finger, the contents 
 fluid blood and retained in the tube by closure of 
 the abdominal opening which has occurred at some 
 prior inflammation. The lesion is usually only temporary, 
 the blood is reabsorbed, and the symptoms gradually 
 subside. 
 
 The second variety represents a graver condition. 
 There will probably be extreme dilatation of the tube, and 
 an extremely thickened and infiltrated wall. On opening 
 the tube it will be found filled with a syrupy, chocolate 
 colored blood, or more often with a clearer liquid formed 
 of a watery fluid and blood. Clots may form in layers on 
 the walls, or in little fibrous masses lying free in the cavity. 
 Various explanations have been offered as to their produc- 
 tion. First, that there is originally disease of the inner 
 surfaces of the tube, and from this a true hemorrhage 
 occurs at each menstrual epoch. This blood coagulates, 
 filling the ampulla. A second hemorrhage occurs with 
 coagulation of its blood around tho original clot. This 
 process is repeated time and again, until largo masses are 
 produced, which in time soften in the centre, and lead to 
 the conversion of the entire mass into a collection of blood 
 debris. The second explanation is that it follows a 
 pyosalpinx or hydrosalpinx, as tho result of traumatism, 
 or twisting of tho pedicle or inner end of the tube. Tho 
 third explanation presupposes a tubal pregnancy arrested 
 in its development by the death of the foetus. 
 
306 
 
 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 Tubo-ovarian abscess. When the inflnmmntory 
 process extends to the peritoneum in cases of chronic 
 salpingitis, it is sure to involve the ovary. The first effect 
 will be thickening of the capsule, which in turn prevents 
 the rupture of the ripe ovarian follicle. The tension pro- 
 duced gives rise to considerable disturbance and pain, and, 
 as the enlarged follicles cannot discharge their contents, 
 it necessarily follows that an ovary which has long been 
 the seat of peri-oophoritis will be largely converted into 
 
 Fig. 94— Pyosalpinx and ovarian abscess. 
 
 cystic spaces (cystic ovaritis), two or more of which may 
 become confluent, and form a cyst the size of a walnut. 
 As such p cyst enlarges, it not unfrequently comes in con- 
 tact with a dilated pus-containing ampulla, and by mutual 
 contact adhesions form and absorption takes place between 
 their walls, and the cyst becoming infected, a tubo-ovarian 
 abscess is the result. 
 
 Atrophy of the tube may result from the destructive 
 action of pelvic suppuration. After a partial atrophy of 
 the walls by cystic degeneration, a rupture and discharge 
 of the contents may be followed by cicatricial contraction 
 and partial obliteration. Traces of mucous membrane 
 and muscular fibre may remain, but the chief part consists 
 
DISEASES OF THE FALLOPIAN TUBES. )}07 
 
 of conuoctive tissue bo contracted as to rooemblo a fibrous 
 cord. 
 
 Symptoms. Tho clinical picture does not materially 
 differ from those drawn of non-cystic salpingitis. Tlu^re 
 are the same pains, and the same menstrual disorders. At 
 times there may be a sudden flow of a certain purulent, 
 serous, or bloody fluid following an attack of colicy pains, 
 occurring at irregular intervals of a month or six months. 
 Unless there is leakage, or rupture into the abdominal 
 cavity, no marked constitutional symptoms may be present, 
 and it is possible for a woman to carry about with her two 
 sacs filled with pus, without any serious phenomena, or 
 even seeming to suffer from their presence. Between the 
 initial period of formation and the final period of inflam- 
 mation of surrounding parts, and efforts at spontaneous 
 evacuation, pyosalpinx passes through a torpid and latent 
 phase, during which the rational symptoms seem to be 
 exactly similar to those of chronic salpingitis, and the 
 physical signs in no wise different from those of hydro- 
 salpinx and hsematosalpinx. 
 
 Two groups of symptoms are really characteristic; the 
 pain which directs attention to the uterine appendages, 
 and the local examination which results in the finding of 
 a tumor at one or both sides of the uterus. Physical 
 examination should be undertaken with the utmost care, 
 as serious and even fatal accidents have been caused by 
 too rough handling of a pyosalpinx. By bimanual exam- 
 ination, a pear-shaped body can be made out, extending 
 from the side of the uterus, and connected to it by a 
 slender pedicle which can scarcely be reached. When the 
 tumor is bilateral, it gives the sensation as if " a wallet 
 had been thrown over the uterus, saddle-bag fashion." 
 Fluctuation is rarely felt, but pain is always caused by the 
 examination. Sometimes the tumor falls down into 
 Douglas' pouch, giving in that region the sensation of the 
 presence of an elastic or fluctuating globular mass, incor- 
 
308 MEDICAL AND SURGICAL OYNiECOLOQY. 
 
 porntod with th(i i)OHtorior Hurfnce of the utorus. It is 
 UHimlly purulimt, and is at first frots but grndunlly bc^comos 
 so ndluToiit to the surrounding parts tlmt it is trnns- 
 formod into n voritnblo pelvic nbscess which cannot bo 
 enucleated. 
 
 Diagnosis. Appendicitis is distinguished by the high 
 position of the exudate, by the seat of the pain being 
 abdominal rather than pelvic, and radiating towards the 
 umbilicus, rather than into the hips, or down the thighs. 
 The attack is generally attended by disorders of the 
 stomach or bowels, and with much greater tendency to 
 nausea and vomiting, and there are usually absent those 
 symptoms specially referable to the genital organs. 
 
 Pyosalpinx is to be suspected, if the dilatation of the 
 oviduct follow gonorrhcBal or puerperal infection, and if the 
 tumor be closely adherent. Pyosalpinx is frequently, and 
 hydrosalpinx usually double, while hjematosalpinx is 
 unilateral. While the tumor is still movable it may be 
 mistaken for a small ovarian cyst, and especially for an 
 intra-ligamentous cyst. The latter however is soft, fills 
 the ligament flush with the uterus, and is thus without a 
 pedicle. A parovarian cyst is softer, and has no traceable 
 connection with the uterus, and no adhesions. The 
 differential diagnosis from tubal pregnancy is often 
 difficult during the early months, but there will be the 
 absence of those characteristic symptoms to be referred tr> 
 later on. It may be mistaken for a '- dunculated intra- 
 peritoneal fibroid, but a fibroid is ^' a, insensitive, and 
 can easily be traced to the uterine wall, while the adnexa 
 may possibly be palpated on either side. 
 
 Treatment. As soon as the diagnosis of a cyst of the 
 tube is established, salpingo-oophorectomy must be per- 
 formed. As said before, operative interference should not 
 be undertaken during an acute attack, but if it be of so 
 serious a nature as to threaten general peritonitis, or if 
 
PELVIC INFLAMMATION. 30.) 
 
 there bo (Ijiuger of rupture of the pyosnlpinx, thoughtH of 
 delay muHt not be entertained, ns operative interference in 
 the only way to Have the patient's life. 
 
 CHAPTER XXVII. 
 
 PELVIC INFLAMMATION. 
 
 Much confusion has existed for a long time in the 
 classitication and complete understanding of diffuse in- 
 flammations of the pelvis, and, as a result, a variety of 
 names has appeared in the literature of pelvic inflamma- 
 tion, intended to represent the conditions which, under 
 varying circumstances, seem predominant. The intimate 
 relations existing between the Fallopian tubes, ovaries, 
 peritoneum, cellular tissue, and lymphatics, compels an 
 almost constant intermingling of the lesions of inflamma- 
 tion affecting them, and consequently under the heading 
 "pelvic inflammation," recent authorities are disposed to 
 include all those inflammatory diseases which involve 
 these structures, treating them as if a single disease. As 
 hos already been pointed out, a pyosalpinx rarely exists 
 except it is complicated by pelvic peritonitis, and in all 
 probability by pelvic cellulitis, and the abscesses which 
 form are usually the result of more advanced stages of 
 those conditions. 
 
 There are, however, two forms of inflammation occur- 
 ring within the pelvis, which, from a clinical standpoint 
 at least, deserve separate consideration, and the phrase 
 "pelvic inflammation," as here used, is to bo understood 
 to include the two affections, pelvic cellulitis and pelvic 
 peritonitis. Inflammation of the several viscera contained 
 in the female pelvis are described under their severol 
 headings, and will only be referred to as far as they are 
 concerned in the pathological processes that lead to the 
 two diseases just named. 
 
310 MEUU'AL AN'l) SUIUMCAL OYN^COLOOV. 
 
 PELVK! CELLULITIS. 
 
 Pelvic cellulitis, hIho known by tlu^ Hyiioiiyms para- 
 mrfn'fis niid prri-nfrrinc phliu/mon, is an iaHammatiou of 
 the pi^lvio connective tisHue. Such inflnmmation may be 
 pfimdrji or scrouildrif, tliat is, it may originate in the 
 connective tiwHue itself, or in one of the neighboring 
 structures, and reach the connective tissue by extension. 
 
 The primary form, or that which will now be con- 
 sidered, is an acute infective disease, and differs in no 
 respect from acute inflammation of the connective tissue 
 in any otlier part of tlie body. Chronic pelvic cellulitis is 
 always a secondary affection complicating inflammation 
 of some other part. 
 
 Etiology. Primary pelvic cellulitis is always a result 
 of septic infection. Its most common source is the 
 absorption of septic matter owing to laceration of the 
 cervix uteri, or of the upper part of the vagina, during 
 labor. Other sources of infection are the various 
 surgical manipulations practised on the vagina and cervix. 
 The lymphatics are the channels by which the poison is 
 conveyed to the connective tissue, hence there is always a 
 certain amount of lymphangitis associated with cellulitis. 
 It is highly probable that the lymphatic glands are also 
 generally implicated, particularly the lumbar which re- 
 ceives the lymphatics from the broad ligament and body 
 of the uterus, and the hyjjogastric or pelvic glands which 
 roceive the lymphatics from the cervix and upper part of 
 the vagina, and as such have been described as pelvic 
 lyinplimufitis. 
 
 Pelvic cellulitis occurs with or without formation of 
 pus. In tlie latter case there is an exudation of coagulable 
 lymijh with oedema into the tissue of the infected area, 
 which at first produces increase of '^ulk without manifest 
 alteration of consistence. Very soon the inflamed tissue 
 becomes stiff and indurated, and, at a later stage, seems as 
 
PELVIC INFLAMMATION. 311 
 
 hard nn cartiln>^i\ Tliiw iiiHnmmatory cxiulntioti may 
 gradually uiidorj^o absorption, and oviuitunlly diHappoar, 
 or it may trrminato in wiippuration, with the formation of 
 a p(>lvic! abHC(*H8. Usually thoro in a Hin^^ltt abHcoHH cavity, 
 but ocoaHionally ntivural an* formod. 
 
 Symptoms. Polvic cellulitis is often ushered in by a 
 chill or rigor. In puerperal cases this usually occurs on 
 the second or third day aft(>r dtlivery, but it may be later. 
 In non-puerperal cases it seldom exceeds a day or two. 
 The tempiTature rises, and the pulse becomes (quickened. 
 Severe pain is peldom present, unless the inflammation 
 extends to the neighboring peritoneum. When suppura- 
 tion has occurred, the most marked symptom is progres- 
 sive emaciation, associated with pallo •, or a peculiar 
 sallowness of the skin. There is complete anorexia and 
 the bowels are usually constipated, though occasionally 
 there is diarrlioja. 
 
 In the early stages, local examination does not give 
 much information. After the lapse of several days, the 
 exudation in the tissue of the affected area becomes 
 densely hard. When the infection has occurred at the 
 upper part of the vagina, or through the cervix, the latter 
 loses its normal mobility, and the supra-vaginal ti-ssues on 
 the affected side are tender, p.vd more or less hard and 
 unyielding. It is seldom that both sides of the pelvis are 
 uniformly affected. In the majority of cases the inflam- 
 mation spreads laterally along the base of the broad 
 ligament, and then passes toi ward to the tissues beneath 
 the reflection of peritoneum on the anterior abdominal 
 wall, and the induration produced there takes the form of 
 a broad band lying along the upper border of the inner 
 portion of Poupart's ligament. Sometimes the exudation 
 spreads upward and outward from above Poupart's liga- 
 ment into the iliac fo.ssa, interfering with the action of 
 the psoas and iliacus muscles, and causing the patient to 
 keep the thighs flexed. In some instances the inflamma- 
 
312 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 tion passes bnckwnrcl instead of forward, producing an 
 exudation in the tissues of the utero-sacral ligament, in 
 the tissues surrounding the rectum, and in those beneath 
 the peritoneum lining the posterior pelvic wall. ^\' hen 
 the body of the uterus is tlu^ starting point of the cellulitis, 
 and the broad ligament the seat of the exudation, bimanual 
 examination will reveal a hard, smooth, flattened, slightly 
 movable tumor by the side of the uterus, and inseparable 
 from it. 
 
 Pelvic abscess. When a pelvic abscess forms, the 
 situation of the abscess, and the position where it may be 
 expected to point, will u ipend upon the direction in which 
 the inflammatory exudation has extended. When the 
 inflammation is seated in the tissues at the base of the 
 broad ligament, and passes forward, forming an area of 
 induration above Poupart's ligament, the presence of 
 suppuration is manifested by oedema in the skin over the 
 indurated area which pits on pressure; by the signs of 
 deep seated fluctuation, and by the eventual pointing of 
 the abscess a little above Poupart's ligament. When the 
 inflammation extenc s backward, and suppuration occurs, 
 the abscess is formed beneath the peritoneum covering 
 the back of the pelvis, and, as free access is difficult, 
 burrowin is almost inevitable. Extension into the iliac 
 fossa and the loin is more particularly apt to take place 
 when the posterior pelvic wall is the seat of an abscess, 
 the abscess pointing either at the iliac crest or above it. 
 Sometimes the pus leaves the pelvis by the sciatic notch, 
 and follows the course of the gluteal vessels. In other 
 instances it may make its appearance in ScarpaV *^riangle. 
 Pelvic abscesses may, though very rarely, discharge them- 
 selves into the rectum, vagina, or even the bladder. The 
 usual time for an abscess to point is from the seventh 
 to the twelfth week. 
 
 Diagnosis. Pelvic cellulitis may bo mistaken for 
 hoematoma of the broad ligament, or a fibroma of the 
 
PELVIC INFLAMMATION. 313 
 
 uterus. The history of the case, nnd the fibHonce of symp- 
 toms of severe ilhiess will, as a rule, serve sufficiently to 
 distinguish a luismatoma from an inflammatory condition. 
 Hrematoma occurs suddenly, either from rupture of a 
 pregnant tube, or of a varicose vein in the broad ligament. 
 In either case the onset is usually marked by sudden pain 
 and faintuess, and usually also by an attack of vomiting. 
 In the case of rupture of a pregnant tube, one or two 
 menstrual periods will have been missed, and attacks of 
 pain will have occurred in the lower part of the abdomen, 
 generally at one side, with slight irregular hemorrhages 
 from the uterus. It must not be forgotten, however, that 
 a h.'i3matoma may become infected and undergo suppura- 
 tion, when the symptoms will be similar to those of pelvic 
 abscess due to cellulitis. In regard Lo myoma, no great 
 difficulty should arise, unless developed laterally between 
 the layers of the broad ligament, and complicated by an 
 attack of localized peritonitis. The mobility of the ".ervix, 
 and the absence of pain and tenderness, as well as the 
 absence of the constitutional symptoms attending cellulitis, 
 should readily diagnose it from the latter condition. 
 
 Prognosis. Except in those severe forms in which 
 cellulitis forms only a part of a general septic process of 
 the most acute and fatal type, the disease usually termi- 
 nates in recovery. As soon as th- fever subsides the 
 exudation begins to undergo absorption, and will have 
 entirely disappeared in a few weeks. Should the fever 
 not subside in the course of five or six weeks, suppuration 
 has probably occurred, and the duration and progress of 
 the illness will then largely depend on the direction ii \i 
 the pus may take in its efforts to reach the surface. In 
 the large majority of cases the abscess will point above 
 Poupart's ligament, where it can be opened. These cases 
 almost invariably do well. In the rarer cases, where 
 suppuration occurs at the back of the pelvis, the pus is 
 longer in reaching the surface, and is apt to burrow. 
 
314 MEDICAL AND SUROICAL GYNJICOLOGY. 
 
 Such cnHoa often Inst a long timo nnd are very trying upon 
 tlio pntiont. 
 
 Treatment. Romomboring that this diHoaso which 
 pr()(hic(^H Huch wi(h> sprimd destruction, and ofton danger- 
 ous and oviMi fatal results, has its origin in septic infection, 
 the neces^:ity for strict asepsis, or surgical cleanliness, 
 becomes fully apparent. If freedom from infection could 
 be ensured to every parturient woman, and a similar free- 
 dom extended to every woman who is submitted to vagiual 
 examination and manipulation, pelvic cellulitis, as a 
 primary affection, would entirely disappear. It is doubt- 
 ful whether, when once an attack of pelvic cellulitis has 
 been initiated, it is possible to modify to any great (^xt(^nt 
 the course of the disease, hence strict care should be tak^^n 
 not to do harm by meddlesonn^ interf(5rence or frequtnit 
 examinations. 
 
 The state of the bowels should receive the most careful 
 attention, and a regular course of aperient medicine should 
 be kept up. A mild febrifuge mixture, containing liquor 
 ammonije acetatis, or citrate of potash, may be admin- 
 istered. The tendency to emaciation calls for generous 
 dietary, and the X)fttient's appetite should be tempted by 
 every means available. When induration and pain are 
 felt in the pelvis, hot fomentations kept in place by a 
 bandage, or hot water bottles, should be applied to the 
 lower abdomen. Vaginal douches of hot water should 
 be administered frecpiently, after which a boro-glyceride 
 tampon, or one saturattnl with a ten-per-cent. solution of 
 ichthyol in glycerine may be inserted in the vaginal 
 fornix. When there are evidences ot suppuration, ([uinine 
 may be administered, and, if necessary, the system sup- 
 ported by stimulants. The abscess should be opened as 
 soon as fluctuation is detected, or there is the faintest 
 indication of pointing, and treated on general principles. 
 The point for incision, whether intra-vaginal or external, 
 must depend largely uj)on the direction which the abscess 
 
PELVIC INFLAMMATION. 315 
 
 HoottiH to bo tiiking, and the dogroo of pointing in that 
 direction. 
 
 (^lironio prlvic oollulitiH doos not oxist an nn indopon- 
 dont (Uhc^uho, or nn a sociuol to tlu^ Jicntc^ form, but it occurs 
 occjiHioruvUy fiH a Hc^condary rosuit of purulent HalpingitiH. 
 It oidy involves tlu^ parts immc^diati^ly contiguous to tlio 
 intlanu>d structures, and never gives rise to the broad 
 band of induration in the lower part of the abdomen so 
 common in the primary affection. 
 
 PELVIC PERITONITIS. 
 
 Pelvic peritonitis, also known by the synonyms peri- 
 mctrHis, peri-i^dlpiiuiitis, and pcri'-ooplioritis, is an in- 
 flammation of that portion of the peritonc^um situated 
 within the pelvis. It is much more common than pelvic 
 cellulitis. In a large majority of cases, if not in all, it is 
 an infective process, due either to the presence of micro- 
 organism or to their chemical products. 
 
 Etiology. Pelvic peritonitis, as now understood, 
 probably never occurs otherwise tlum as a result or com- 
 plication of some preexisting disease within the pelvis. 
 Not infre(iuently, however, it is the first indication of the 
 presence of such disease, for the symptoms of peritonitis 
 are for the most part acute, and of a character to compel 
 attention, whereas those of the original disease are often 
 so slight as to be scarcely noticeable. 
 
 Sdtpiiif/ifis (did its ('omplicdiions. In the vast majority 
 of cases pelvic peritonitis is the result of inflammation of 
 t'nC Fallopian tubes. The methods of infection of the 
 p(4vic pi^ritoneum, by means of the tubes, and the effects 
 produced, immediate and remote, have already boon con- 
 sidered when speaking of salpingitis. 
 
 New (jrowfliH. Peritonitis may result from twisting of 
 the pedicle of an ovarian tumor, or by the presence of any 
 new growth in the pelvis, and it is in this way in 
 ordinary cystic disease adhesions are formed. 
 
316 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 SepticAvmid. When septic infection of a severe type 
 follows abortion, parturition, or surgical manipulations, 
 giving rise to diffuse septic infection of the pelvis, the 
 pelvic peritoneum will also be involved. 
 
 Pelvic cellulitis. Pelvic peritonitis may result from 
 the spread of the inflammatory process from the pelvic 
 connective tissue, more particularly when it is attemled 
 by suppuration. 
 
 Disease of the vermiform (ijypewlix is not to be for- 
 gotten. Occasionally the appendix is found lying within 
 the pelvis, and, when investigating a case of pelvic 
 peritonitis, it is well to remember that it may arise from 
 disease of that organ. 
 
 Pathology. The earliest change produced in the 
 peritoneum is hyperemia, with cloudy swelling of the 
 endothelium. The membrane loses its normal, smooth, 
 shiny appearance, and becomes dull, dry, and slightly 
 roughened. Plastic lymph is then poured out on the 
 surface, which leads to rapid formation of adhesions be- 
 tween the adjacent surfaces. In addition to the lymph 
 effused, there is also an eft'usion of serum which tends to 
 accumulate, principally in Douglas' pouch, but it also 
 tends to form collections of fluid in different parts of the 
 pelvis, where spaces intervene between the adhesions. 
 One of the earliest results of the adhesive process is to 
 roof in the contents of the pelvis from that of the general 
 peritoneum. The intra-i^eritoneal collections of serum 
 are absorbed, but the adhesions formed continue for a long 
 time, and many of them become permanent, with the 
 result of producing more or less serious interference with 
 the functions of the vise ^^a involved. When the disease 
 causing the peritonitis is purulent, the peritonitis is also 
 apt to be purulent, and as a result, instead of accumulations 
 of serum amongst the adhesions, collections of pus are 
 ' irmed — intra-peritoneal abscess. 
 
PELVIC INFLAMMATION. 317 
 
 Symptoms. An attack is characterized by pain in the 
 lower part of the abdomen, sudden in the onset, and at 
 first severe in character. There is rise of temperature, 
 rapidity of pulse, and intestinal disturbance, indicated by 
 vomiting and local or general distension. After the acute 
 pain has subsided, movements of the body are painful, 
 owing to the tenderness of the inflamed parts. There is 
 usually constipation, and pain preceding defecation and 
 during micturition. In subacute and chronic cases, pain 
 in the back, and inability to undergo physical exertion, 
 are the most common and may be the only symptoms, 
 while trifling causes, such as slight over exertion or ex- 
 posure to cold readily provoke localized acute attacks. 
 Such recurrent attacks are especially apt to occur when 
 the chronic pelvic peritonitis is kept alive by the presence 
 of pelvic suppuration, and serves as a better guide to the 
 diagnosis of pus in the pelvis than does the temperature. 
 In course of time, patients become ill and emaciated, and 
 entirely incapacitated for work of any kind, and may even 
 become invalided. 
 
 During an acute attack of pelvic peritonitis the patient 
 lies on the back, usually with the knees drawn up. The 
 lower part of the abdomen is extremely tender to the 
 touch, and the walls over the area affected more or less 
 rigid. On vaginal examination, the parts at this stage 
 will be too sensitive to allow of a satisfactory investiga- 
 tion. In there be any depression in the vaginal vault, it 
 will be central and not lateral, owing to the filling up of 
 Douglas' pouch. There may be tenderness and a sense of 
 resistance on pressing the fingers upwards into one or 
 both lateral fornicos, but it will not be possible to map 
 out any definite swelling until the acute symptoms have 
 subsided. After this has occurred, a careful bimanual 
 examination will probably reveal an inflamed Fallopian 
 tube as a fixed, irregular, tender, sausage-shaped swelling, 
 and gradually increasing in size as it extends outwards 
 
318 MEDICAL AND SURGICAL GYN/ECOLOGY. 
 
 from tho uterine cornu. As the patient recovers from the 
 immediate effects of the attack, the hardness of tho 
 peritoneum gradually disappears, and tho outline of the 
 adherent appendage more readily made out. 
 
 Diagnosis. Pelvic cellulitis. Pelvic cellulitis is a 
 much rarer disease than pelvic peritonitis. Its origin is 
 exclusively septic, never gonoiTlioeal or tubercular, and is 
 essentially a disease of the puerperium, or one following 
 surgical manipulation. Cellulitis, when uncomplicated, 
 is unattended by pain, or at any rate by severe pain. In 
 both diseases there is swelling in the lateral regions of the 
 pelvis, but in cellulitis the swelling is usually unilateral, 
 smooth, uniform, attended with fixation of the vaginal 
 vault, and of stony hardness. In peritonitis it is more apt 
 to be bilateral than unilateral, and instead of being smooth 
 and of uniform consistence, is irregular in outline and 
 unequal in consistence. In cellulitis the cervix is apt to 
 be surrounded by a hard thick collar, in which it is 
 immovably set, whilst in peritonitis it is not present, and 
 the impairment of mobility of the cervix is never so com- 
 plete. In cellulitis the rectum will often be felt surrounded 
 wholly, or partially, by a belt of exudation of ston; hard- 
 ness, fixing the coats of the bowel at that pa.t, and 
 narrowing the cavity of the canal. In peritonitis en- 
 largement will be in Douglas' pouch, and will bo less 
 hard, and will not affect the mobility of tho walls of the 
 bowols to the same extent. When cellulitis has its seat 
 in the broad ligament, bimanual examination will reveal 
 a smooth, hard, flattened tumor by tho side of and 
 continuous with the margin of the uterus. This tumor can 
 be moved backward and forward within certain limits. 
 The swelling caused by the inflamed and adherent 
 appendages in pelvic peritonitis is, on the contrary, of 
 irregular contour, and is not continuous with the uterus, 
 but on a plane behind it, and quite fixed. 
 
PELVIC INFLAMMATION. 319 
 
 Pelvic ho'imttocele. The diagnosis will largely dopond 
 upon tho clinical history. As pelvic hremntocele, in n 
 majority of cases, is a complication of tubal pregnancy, 
 there will usually be a history of early pregnancy, and of 
 a sudden attack of pain accompanied by great faintness. 
 The patient will have a blanched appearance, or that of 
 shock. The effusion is at first fluid, but soon acquires a 
 doughy consistence, and later becomes diminished in bulk 
 and harder. 
 
 Prognosis. The prognosis in pelvic peritonitis is 
 much less favorable than in pelvic cellulitis. The mor- 
 tality is higher, and the after effects in those who recover 
 are apt to be much more troublesome. The damage done 
 to the uterus, ovaries, and tubes during an attack fre- 
 quently produces sterility. Displacements of the uterus 
 are apt to follow, together with the symptoms induced by 
 such conditions, and the normal action of the bowels are 
 apt to be disturbed. 
 
 Treatment. Preventative. Inasmuch as the large 
 majority of non-purulent cases of pelvic peritonitis is duo 
 to gonorrhoeal salpingitis, care should be taken to 
 destroy gonorrhceal infection as soon as discovered, and 
 before it has gone beyond the reach of local applications. 
 Strict attention to surgical cleanliness in every form of 
 manipulation will often prevent the occurrence of salpin- 
 gitis, the forerunner of pelvic peritonitis. In those who 
 have once been the subject of pelvic peritonitis, it is im- 
 portant to avoid such causes as are likely to provoke a 
 relapse, such as exposure to cold during the menstrual 
 period, over exertion, prolonged standing, and inattention 
 to the bowels. 
 
 The medicnl treatment consists in very much tho same 
 measures as those recommended for the relief of pelvic 
 cellulitis. Pain being a most distressing symptom must 
 be relieved by small doses of morphia, and the tendency 
 to the formation of scybala prevented by the careful use 
 
320 MEDICAL AND SURGICAL GY> ECOLOGY. 
 
 of onomatn. Sliould tho stnto of tho pulso indicate it, 
 stimulants in tho form of brandy or whiskey should bo 
 given in defined and measured doses, and the effects care- 
 fully watched. Tendency to collapse should bo mot by 
 the application of hot water bottles, and by hypodermatic 
 injections of strychnia. 
 
 Surgicdl measures, when necessary, are best deferred 
 until the acute symj^toms have subsided, and until an 
 opportunity has been afforded of making a thorough 
 bimanual examination and arriving at a correct diagnosis. 
 If it is a first attack, and the symptoms such as to lead to 
 the diagnosis of non-purulent inflammation of the appen- 
 dages, operative interference should not for a moment be 
 recommended. If, on the other hand, the patient has had 
 several attacks previously, and the swelling has attained 
 such dimensions as to make it fairly certain that pus is 
 present, nothing but tho operative measures advised when 
 speaking of salpingitis will be of any avail. 
 
 CHAPTER XXVIII. 
 
 DISEASES OF THE OVARIES. 
 
 Malformations. One or both ovaries may be con- 
 genitally absent but such a condition is very rare. When 
 it does exist, it is generally only a part of a complete want 
 of genital development manifested by the parts makiiig 
 up the vulva, vagina, and uterus. More common than 
 absence is rudimentary development, in which tho ovaries 
 may or may not contain Graafian follicles. Tho gland 
 itself may bo of nearly normal size and in a normal 
 situation, but the gland contents, the Graafian follicles 
 and ovules may be absent. Such conditions may be 
 found in connection with a normal uterus, but most 
 commonly thoy are found associated with arrest of 
 
DISEASES <»F THE OVARIES- DISPLACEMENTS. li'll 
 
 (lovolopinont of timt orgnii. A dinf^aosis in suoli cnsos is 
 extremely difficult, but the condition may be presumed 
 when the ovnries cannot be palpated bimanually, com- 
 bined with want of development in the other genital 
 organs, with absence of the usual signs of the menstrual 
 crisis, and with lack of general constitutional vigor and 
 development. 
 
 The ovaries of now-born children may be twice their 
 normal size, a condition which may be due to uniform 
 enlargement of its constituent parts, or to fo)tal inflamma- 
 tion resulting in a preponderance of connective tissue, 
 and a partial or total disappearance of the (xraafian 
 follicles. Accessory ovaries immediately joining the 
 normal ovary, and included usually within the same 
 peritoneal investment, have been found. The ovary may 
 likewise be constricted so that it consists of twoi)ractically 
 independent parts. A true supernumerary ovary, far 
 removed in station from its fellow, is extremely rare. 
 
 DISPLACEMENTS. 
 
 Congenital displacements of the ovaries are very rare. 
 In the early embryo they are situated, like the testicles, in 
 close relation with the kidneys, but soon after birth they 
 are found to occupy a position in the true pelvis. Only 
 in extremely rare instances have ovaries been found re- 
 tained in their original relations with the kidneys. 
 
 Congenital inguinal hernia of the ovary is also rare, 
 but when it occurs, it is generally due to deficient develop- 
 ment of the round ligament, by which the ovary, tube, and 
 sometimes one horn of the uterus, are pulled through the 
 canal of Nuck. There are usually no symptoms until 
 menstruation sets in, when there may be much disturbance 
 of that function. The only treatment consists in extirpa- 
 tion. 
 
 Acquired displacements of the ovaries are not un- 
 common. Any influence which increases their weight, or 
 
322 MEDICAL AND SURGICAL GYNiECOLOOY. 
 
 drnwH upon thorn directly, or nets upon tliom by trnction, 
 mny cauKo tlicm to lonvo their position, nnd Honu^times to 
 such an extent ns to pnss out of the pelvis in the form of n 
 hernia. 
 
 Cduscs. Displacement of the ovaries may be brought 
 about by any causes which will increase their weight; such 
 as inrtnmmatiou, hypertrophy, or cystic degeneration. 
 They may be a(!ted upon by contraction of effused lymph 
 resulting from pelvic peritonitis, or by contraction of the 
 ovarian ligaments drawing them out of place. It may be 
 brought about by displacements of the uterus, more par- 
 ticularly retroversion and retroflexion, or by insufficient 
 support from below, especially when it is the outcome of 
 a weakened or ruptured perineum. 
 
 Displacements may bo subdivided into intra-pelvic 
 and extra-pelvic, according to whether the ovary is found 
 within, or outside the pelvis. 
 
 Intra-pelvic displacement, or prolapse of the ovary, 
 is a common disease, and one of considerable practical 
 importance. When the ovary becomes displaced it sinks 
 backward, downward, and inward, first upon the retro- 
 ovarian shelves, and next into Douglas' pouch, describing 
 in its descent an arc of a circle. 
 
 Symptoms. The symptoms will vary according to the 
 causes which have induced the displacement, and to 
 the possibility of its return to its normal position. 
 Ovaries prolapsed behind the uterus manifest themselves 
 by more or less severe, or constant pain in the lower part 
 of the back, usually referred to the sacral or rectal region, 
 and intensified by the passage of hardened feces or by the 
 act of coition. There is a further sensation of dragging 
 or bearing down, and when the ovary is adherent these 
 symptoms are usually aggravated. 
 
 The (iimjnosis is usually made by vaginal examination. 
 Tile prolapsed ovary can readily be touched in its abnor- 
 mal position, giving a peculiar sensation of faintness and 
 
DISEASES OP THE OVARIES— DISPLACEMENTS. 323 
 
 nauHOft wluui prossod upon. It mi^ht bi^ iniHtakeii for a 
 swollon tube, but tho latter is more sausa^e-HhapiHl. A 
 small podunoulatod fibroid in hardor and not stMisitive, 
 while scybala may be indented or crushed without much 
 pain, and may be removed by enemata or cathartics. 
 
 Tr<'((tm<'iit. The treatment consists in replacing the 
 ovary, if it is movable, by digital manipulation, or by 
 posture in the genu-pectoral position, and, after replace- 
 ment, its return to the pelvic cavity prevented by some 
 suitable support, suoh as a Thomas' retroflexion pessary, 
 or astringent balls or tampons of cotton packed behind 
 the cervix. If a retro-displacement of the uterus exists, 
 the reposition of that organ, together with the ovaries, and 
 its retention by a suitable pessary will usually suffice. If 
 the ovary is adherent it will be necessary first to endeavor 
 to stretch and break up adhesions. This may be done by 
 pelvic massage, and by packing the posterior fornix of the 
 vagina, while in the genu-pectoral position, with cotton 
 balls, the first few inserted being i opregnated with boro- 
 glycoride,or a ten-per-cent solution rf ichthyol in glycerine. 
 If these measures fail recourse may be had to radical 
 methods. If there are no adhesions and the uterus is 
 freely movable, Alexander's operation may be performed; 
 if otherwise coeliotomy .must be undertaken in order that 
 the adhesions may be broken up, after which the uterus 
 should be retained in place by ventral fixation. 
 
 Extra-pelvic displacement, or hernia of the ovary. 
 The ovary p.ay pass through the same openings as other 
 herniee, bxc all but two forms are exceedingly rare. 
 
 Irufuinal. The passage of the ovary into or through 
 the inguinal canal can only occur when the tube and 
 infundibulo-peivic ligament are unusually relaxed and 
 elongated. When such a condition exists hernia may be 
 produced by a fall or similar violence, and the ovary, in its 
 abnormal place, may become inflamed, or undergo cystic 
 or cancerous degeneration. 
 
324 MEDICAL AND 8UROICAL OYN JICOLOOY. 
 
 Tlic ilidj/iiosla niny bc^ nmdi^ by tlu^ prc^Hoiicc^ of a tumor 
 ill tho inj^uinul region oorrtiHpoiidiiig in Hhnpi^ to that of 
 tho ovary, nnd producing a peculiar sickening Honsation 
 when prcHHcd ui)on. Bimanual examination revoals 
 abHcnco of tho ovary from the pelvis and tilting of the 
 corresponding uti-rine cornu to that side, while backward 
 and forward movement of the uterus causes the tumor to 
 move. 
 
 The hernia may be reduced by taxis, and held back by 
 the application of a suitable truss. Herniotomy may be 
 necessary to relieve the imprisoned ovary, and wIumi per- 
 formed may be followed up by a radical operation to 
 securer permanent results, or by extirpation of the ovary 
 if it is found to be diseased. 
 
 Criit'id. The ovary may make its way through the 
 crural ring into the crural canal. Tho same symptoms 
 and treatment are applicable in this variety as in the 
 former. 
 
 HYPER-EMIA AND H<EMATOMA. 
 
 Hyperaemia of the ovaries occurs to a considerable 
 extent during each menstrual period, and often just pre- 
 vious to, and during coition, but should liyperiBmia be 
 kept up for any length of time, or is frequently repeated, 
 it will result in persistent dilatation of tho vessels, and 
 some serous effusion into the stroma; and in more stwore 
 cases hemorrhage into the Graafian follicles may take 
 place. The hemorrhage may bo confined to one follicle, 
 or it may occur in many. When thoro are many follicles 
 aifooted, rupture of their septa may take place, producing 
 luTBmato —1. of a size varying from a pea to a walnut, or 
 even Ir 
 
 ^ iiage into the stroma is apt to assume the form 
 
 o jrous minute extravasations. The blood may bo 
 
 cc /lotely absorbed, or remain as a coagulnm, or as a 
 mass of tarry fiuid. The fluid part may be absorbed 
 altogether, leaving a granular pigment, or tho solid parts 
 
DISEASES OF THE OVAKIES—HYI'ER^MIA. .'^25 
 
 limy b(> abHorbinl, ho that only a cyHt HlU'd vvitli Hcrouw 
 tluid riMnaiiis, or Huppuration may Hot in. An oxti^nHive 
 litMiiorrha^o may causo rupturo of tlio ovary, and the 
 bh)od pouring into tho poritonoal cavity or ponotrating 
 between the two layerH of the broad ligament, will form a 
 htematocelo. 
 
 Kfiolof/jf. It may be due to anything which will 
 produce venouH staaiH, such as maHturbation, venereal 
 excesses, uterine displacements, and sedentery habits, or 
 it may arise from causes which produce a disordered 
 condition of the blood, such as severe burns, phosphorus 
 poisoning, scurvy, typhoid fever, or septicsemia. 
 
 Hijmi)f()ms. A patient affected with hypeniMnia of the 
 ovary is likely to suffer from menorrhagia, and accom- 
 panying it there will bo pain in the region of the ovaries 
 am extending down the ti ighs- and sometimes neuralgia 
 of t. e breasts. Hemorrhage into the ovary may take place 
 without giving rise to any symptoms. If the collection 
 is large, it causes severe pain, and even nausea and vomit- 
 ing, and on examination the ovary will bo found enlarged. 
 Hyperemia and luematoma may be diagnosed, if, in a 
 healthy person, one or both ovaries suddenly become 
 enlarged and tender without fever. In those who have 
 been affected with blood dissolution, luematoma may be 
 inferred if the patient is seized with ovarian pain, and a 
 movable tumor can be felt in the pel. "?. 
 
 Tvcdtmenf, In hyperemia, rest in bed is demanded; 
 but to be complete, physiological rest must bo secured as 
 well. The general health should be improved, suitable 
 tonics administered, and the bowels properly regu- 
 lated. Some form of local treatment for tho purpose of 
 reducing general hyperremia should be instituted, such as 
 occasional counter-irritation over tho lower abdomen by 
 moons of tincture of iodine or blisters, by hot vaginal 
 douches, and by the use of ichthyol or boro-glycoride 
 tampons. Later the patient may be allowed to return to 
 
326 MEDICAL AN1» SURGICAL GYNECOLOGY. 
 
 out door oxorciso, still keeping up the local and general 
 treatment, but rest in bed must be insisted upon during 
 each menstrual period. Should an acute attack occur 
 at any time, the patient sliould at once be put to bed, 
 an ice bag placed over the hypogastric region, and a dose 
 of morphia administered to relieve the pain. If the 
 ovaries have suffered in structure, the result ot prolonged 
 hypera^mia, or from repeated attacks, they should be 
 removed. 
 
 OOPHORITIS. 
 
 Oophoritis, or inflammation of the ovary may be 
 either acute or chronic. 
 
 ;ute oophoritis. The inflammation may bogin on 
 the surface, 'pcri-oophorifis; in the anterior, intcrstitidl 
 oophoritis; in the follicles, /o///c«/(^ir oophoritis; or in the 
 stroma, intor-follicnl<ir oophoritis. As a rule both organs 
 are involved. 
 
 Etiology. Acute oophoritis is infrequently found 
 out.jide the puerperal state. It may, however, be ca\ised 
 by hyperemia and luBmatomaj or by any of the causes 
 mentioned as liable to produce that condition; or by a 
 sudden suppression of the menstrual flow. It may follow 
 minor operations, such as the use ol' the .sound, incision of 
 the cervix, or trachelorrhaphy. From proximity of the 
 ovary to the abdominal end of the tube, inflammation of 
 the latter necessitates an almost constant implication of 
 the ovary, peri-oophoritis being here the first form pre- 
 sented. Oophoritis may however occur quite indepen- 
 dently of salpingitis. The lymphatics leading from the 
 ovary connect in the meshes of the broad ligament with 
 those coming from the upper part of the uterus, and it is 
 thus easy for pathogenic germs to reach the ovary through 
 those channels and infect them, without the presence of 
 salpingitis. Interstitial oophoritis is the form here pre- 
 sented. 
 
DISEASES OF THE OVARIES— OOPHORITIS. 1327 
 
 Wlietlior the initial lesion begins within or without the 
 organ, the results will generally be the same, for by trans- 
 mission through the lymphatics outside implication will 
 extend to the interior, and inside implication to the 
 exterior. When the disease begi- •? as a peri-oophoritis 
 the surface will be found covered th a serous, plastic, or 
 purulent exudation, in accordance with the grade of in- 
 flammatory action present. The ovary wJl be enlarged, 
 and in the plastic and serous types, the cortex will be more 
 or less infiltrated with small round cells, similar to inflam- 
 matory processes in other organs. If the type of inflam- 
 mation be purulent, pus cells will predominate. Beginning 
 as an interstitial process, the same elements pervade the 
 organ, the predominance of the simpler inflammatory 
 elements, or those indicative of suppuration, being gov- 
 erned by the presence or absence of septic elements. The 
 Graafian follicles in all cases suffer changes kindred to 
 those going on around them. There is turbidity of the 
 liquor folliculi, with softening and disintegration of the 
 membrana granulosa, and the ovum. 
 
 Course. In the absence of purulent infiltration, it 
 may terminate in resolution, or in connective tissue 
 sclerosis leading to atrophy, or the follicles may be con- 
 verted into cysts, the cva and the membrana granulosa 
 undergoing fatty degeneration. Purulent infiltrati(m 
 leads tO the development of abscesses, coalescence of which 
 may convert the ovary into a complete pun sac, nothing 
 remaining but the tunica albuginea. These pus sacs may 
 become encysted, but the rule is, a continuance of suppur- 
 ation until the pus makes its way through the tunic, when 
 the course will be similar to escape of pus from the tube. 
 
 Sytnpfoms. Often the symptoms are masked by those 
 of the disease which produced it. The ovarian region 
 will be the seat of a burning pain radiating down to the 
 knee, and tc the bladder and rectutn, and occasionally 
 there will be reflex pain in the breast, and not infrequently 
 
328 
 
 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 nausea and vomiting. By bimanual examination it is 
 possible to feel the ovary enlarged and exceedingly tender 
 to the touch. When an ovarian abscess has formed, it 
 will give rise to symptoms similar to the formation of pus 
 elsewhere, and when felt, a sensation of fluctuation may 
 possibly be made out. It is seldom possible to make a 
 certain diagnosis. An inflamed tube or a pyosalpinx is 
 sausage-shaped when palpated, an inflamed ovary or 
 ovarian abscess is round. Pelvic abscess is situated lower 
 down and is absolutely immovable. 
 
 h'ui. 95.— Ovary with many dropsical follicles CLeopold). 
 
 Ti'catntciif. The patient must be kept quiet in bed, 
 with an ice bag over the affected side, and the bowels kept 
 relaxed by means of saline aperients. Pain is to be 
 combated by means of morphia in some form. If the 
 symptoms point to tlie presence of pus, it is to bo removed 
 either by abdominal or vaginal oophorectomy. 
 
 Chronic oophoritis represents certain changes brought 
 about in the ovary the result of repeated attacks of 
 congestion or of acute inflammation, or it may be a 
 chronic process from the beginning. The common changes 
 which occur are (itrophy and cystic dc(jeneration. Atrophy 
 
DISEASES OF THE DVARIES— OOPHORITIS. 32*.) 
 
 is most mnrkocl in conjunction witli adliosions. which, by 
 compn^ssin^ the ovnry, iiicreuso tiic sch'rotic changes 
 in'Uiccd by the acute interstitial form. The whole organ 
 may bo converted into a small mass of connective tissue, 
 with almost entire disappearance of distinct formation. 
 In the ci/sh'c form the albuginea is thickened, and the 
 organ filled with cysts intermixed with comparatively 
 normal follicles. The cysts are transformed follicles with 
 thickened walls surrounded by indurated tissue, the ova 
 and membrana granulosa having undergoiu* fatty degener- 
 ation and absorption, leaving merely limpid Huid. In 
 other cases the cysts may contain a gelatinous or colloid 
 material. Some of these cysts may be so large as to 
 involve the whole ovary. 
 
 Kfiolofji/. Chronic oophoritis is much more common 
 than the acute form, and is often the result of, or follows 
 acute iuHammation. A displaced ovary strongly pro- 
 dispo.ses to it. It is most frequently due to puerperal or 
 gonorrhceal infection, while venereal excesses, masturba- 
 tion, the abuse of alcohol, and syphilis are strong factors 
 in its production. 
 
 Sipfiptoms. The symptoms are often masked by sur- 
 rounding inflammation. The patient compLiins of pain in 
 one iliac fossa, or if both ovaries are affected, as is often 
 the case, in both fossjB, the pain often extending to the 
 rectum, bladder, hips, and down to the knees. The pain 
 is increased at the approach of the menstrual period and 
 during coitus, especially if the ovary is prolapsed. Stand- 
 ing or walking for even a short time gives great fatigue. 
 Menstruation is often irregular and profuse, but in the 
 atrophic form there may be amenorrhcea. Leucorrhooa is 
 a common accompaniment, and often the digestive and 
 nervous system suffer to a greater or less extent. ( )n ex- 
 amination it is extremely difficult to say whether a mass 
 felt through the roof of the vagina is an ovary or tube. 
 
330 MEDICAL AND SURGICAL GYNiECOLOGY. 
 
 Sometimes the enlarged and prolapsed ovary can be made 
 out by its globular form and extreme tenderness. 
 
 Treatment. The management of chronic oophoritis 
 coincides in most respects with that described for chronic 
 salpingitis, and when the case has been seen early, treat- 
 ment may be of great benefit, but when degenerative 
 changes have taken place to any marked extent, it will be 
 readily understood that no immediate benefit can be de- 
 rived. A displaced ovary, or retroverted uterus should be 
 restored to its normal position and retained there. Hot 
 vaginal douches and medicated tampons often give much 
 relief from pain, and absorption of inflammatory material 
 may be promoted by painting the vaginal vault with tinc- 
 ture of iodine. Notwithstanding local and general treat- 
 ment, carried out methodically and persistently, in many 
 cases nothing short of an operation for the removal of the 
 diseased structures will be of benefit, and should be 
 recommended before the patient's health commences to 
 break down from the continued strain on the nervous 
 system. 
 
 CHAPTER XXIX. 
 
 DISEASES OF THE OVARIES CONTINUED. 
 
 NEOPLASMS. 
 
 From a histogenitic point of view tumors of the 
 ovaries have been divided into neoplasms of connective 
 tissue origin, and epithelial neoplasms. The first group, 
 desmoid tumors, includes fihromata, sarcomata, and 
 myxomata, all of rare occurrence. The second group, 
 epithelial tumors, includes cystomata, carcinomata or 
 alveolar epitheliomata, and adenomata or mucoid epithe- 
 liomata. 
 
 For convenience of study, and from a clinical stand- 
 point, they are most conveniently divided into cystic and 
 solid growths. The cystic tumors include simple, pro- 
 
DISEASES OF THE OVARIES— NEOPLASMS. 331 
 
 liferatiiu/, (Irrnioid, and hrodd ligiimont cysfs. The solid 
 tumors nre Jihroniatd, sarcoimita, and aircinomdta, all 
 comparativoly rare. 
 
 OYSTS OF THE OVARY. 
 
 Cysts may originate in any part of the tubo-ovarinn 
 structure; in tlio cortical, medullary, or parenchymatous 
 structure of the ovary; in its inferior border or hilura; in 
 the structures between the tube and ovary in which are 
 found the remains of the Wolffian body, known as the 
 organ of Rosenmuller, or the parovarian structure; or in 
 the hydatid of Morgani, the obliterated remains of the 
 canal of Gartner. Cysts may also develop in the folds of 
 the broad ligament, and then are known as brodd li(j<i- 
 mciit r/y.s'/.s. The cysts may bo nnilociildr with limpid 
 contents, or muUiloculdr with varying contents, some 
 clear and limpid, others thick and viscid, or discolored 
 with admixture of blood. 
 
 From an anatomical standpoint it is important to dis- 
 tinguish cystic growths according to the size which they 
 attain. Some of moderate dimensions may be well toler- 
 ated or give rise to troubles, which, though painful, do 
 not threaten existence. Others, on the contrary, increase 
 in size with the greatest rapidity from the moment their 
 development has been started. 
 
 Small cysts may be subdivided into: — 1. Snidll rosidudl 
 cysts coming from Morgani's hydatid, or the horizontal 
 canal of the parovarium. 2. Follivnldr. 3. Cysis of tlic 
 corpus lutcum. 4. Tubo-ovdvian cysts. 
 
 Large cysts may be subdivided into:— 1, Gldndnldr 
 prolifcrdting. 2. Popillary prolifci'dtiny. 3. Dermoid. 
 4. Parovdridn. 
 
 1. Small residual cysts. In uterine fibromata and 
 ovarian tumors at the start, there are found either on the 
 broad ligament or on the tubes, small transparent vesicles, 
 but are of no surgical interest. They are of three kinds: — 
 
332 
 
 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 i. Cjl^t of the hijddtid of Mor(jffni. Attached to the 
 fimbrinted end of the Fnllopian tube there is generally 
 found a cyst varying from the size of a pea to that of a 
 cherry, transparent, and covered with a single layer of 
 endothelium. This hydatid is the remains of the extremity 
 of the canal of MuUer. 
 
 ii. Siipra-fnhdl ri/sf is no larger than the preceding 
 and has the same appearance and structure. It is probably 
 a micro-cyst of the broad ligament which has s'ipped 
 under the serous membrane, and worked its way up to this 
 unusual position. 
 
 iii. MicA'o-cysts of the broad lujament. Some of the.^e 
 are suspended from Rosenmuller's organ, and some are 
 
 Fig. 96. — niagr.ini of the structures in and adjacent to the broad ligament. (I)oraii.) 
 t. Framework of the parenchyma of the ovary, seat of a simple or glandular nuiltilucular 
 cyst, I a. 2. Tissue of hilum, with, 3, papillomatous cyst. 4. Hroad ligament cyst. 5. 
 A similar cyst al>ove tube, but not connected with it. 6. A similar cyst developed close 
 to 7, ovarian fimliri;p of tube. 8. The hydatid of Morgagni. 9. Cyst developed from 
 the horizontal tube of parovarium ; cysts 4, 5, 6 and 8 are always lined internally with 
 a single layer of epithelium. 10. The parovarium. 11. A small cyst developed from 
 a vertical tube. 12. The duct of Gartner, often persists in the adult as a fibrous cord. 
 13. Tract of that duct in the uterine wall. 
 
 free and of undetermined origin. Only those which 
 originate from the vertical tubes of the parovarium have 
 ciliated epithelium, and are likely to subsequently develop 
 into papillary growths. 
 
DISEASES OF THE OVARIES — NEOPLASMS. 333 
 
 2. Follicular cysts. Hydrops of the Granfinn folliolos 
 wns long coiisidorod the only or chief onuse of Inrgo 
 ovarian cysts. From failure to rupture owing to some 
 morbid cause, particularly inflammation of the appendages, 
 the follicles may form cysts from the size of a hemp seed 
 to that of a walnut (cystic ovaritis). There may be ex- 
 ceptionally an agglomeration of several of these sacs, 
 causing the ovary to become as large as the fist or a foetal 
 head (Rokitansl^ifs tumor). 
 
 3. Cysts of the corpus luteum. This cyst, when first 
 described, was believed to be a corpus luteum of pregnancy 
 transformed into a cyst, but microscopical examination of 
 the walls will show the bud-like papilla* characteristic of 
 the corpus luteum. The recognition of this prevents their 
 being confused with follicular cysts, or with suppurative 
 ovaritis. They are generally no larger than a walnut, but 
 cases have been described in which they have attained 
 the size of an orange. 
 
 4. Tubo-ovarian cysts. The presence of an ovarian 
 cyst not infrequently results in the formation of a tubo- 
 ovarian cyst tlirough its proximity to a distended tube. 
 A dilated follicle or small cyst may rupture into a dis- 
 tended tube with which it is in contact and adherent, and 
 form one sac. They do not usually attain to a large size. 
 The uterine opening of the Fallopian tube may remain 
 pervious and as the fluid increases it passes into the 
 uterus. 
 
 Large cysts. Proliferating cysts are also called myxoid 
 cystomata in opposition to dermoid cystomata, because 
 their inner surface resembles a mucous membrane. The 
 term "proliferating" has been given them because they 
 produce new cysts or papillary growths from their inner 
 surface. There are two varieties, (fUmdnUir and ptipllUo'jj. 
 
 1, Proliferating glandular cystoma has a wall com- 
 posed of the same structures as found in follicular cysts 
 and similar external epithelium, but the internal epithe- 
 
334 MEDICAL AND SURGICAL GYNyGCOLOGY. 
 
 Hum undergoes a remarkable proliferation which results 
 in the development of gland-liko growths. This epithe- 
 lium is polymorphous, but the long columnar is the 
 predominant variety. It is stratified and forms pouches, 
 which are at first placed regularly side by side, and are 
 about the same size, but in consequence of the continued 
 proliferation they become closed, thus forming a secondary 
 cyst in the wall of the primary cyst. When the secondary 
 cyst is formed, the same process of proliferation is re- 
 peated, so that continually one generation of cysts is 
 
 Fio. 97. — Small imillilociilar cyst. (Museuiu of the College of Physicians and Surgeons.) 
 
 formed in tlio wall of another. With the production of 
 new cavities, a r(>duction in their number takes place by 
 the absorption of the partition which separates them. By 
 this continued proliferation of epithelial cells, formation 
 of new cysts, and absorption of their walls, very large 
 tumors are formed, in which, as a rule, one cyst pre- 
 dominates, with a greater or smaller number of secondary 
 cysts in its wall. These cysts are therefore always multi- 
 locular from a pathological standpoint, although they may 
 be considered unilocular from a surgical one. This variety 
 of tumor is by far the most common, and may reach an 
 enormous size. The outer layer of the wall corresponds to 
 the albuginea, is smooth and dense in texture, and pearly- 
 grey or white in color. The inner layer furnishes the 
 
DISEASES OP THE OVARIES — NEOPLASMS. 
 
 335 
 
 connective tissue, and together with the epithelium enters 
 into the composition of the secondary cysts. It is of a 
 reddish color, slightly uneven, and velvety like the inside 
 of the stomach. From the outer layer may grow small 
 excrescences covered with short columnar epithelium. As 
 a rule they have a pedicle. 
 
 Contents. In very small new-formed cysts, the tumor 
 may be one solid mass of cells, but as a rule the contents 
 
 
 '.1^ ''©* 
 
 :°:9©r^ 
 
 *' 
 
 Fig. g8. — Microscopic examination of fluid from ovarian tumors. A. Epithelial cells. 
 H. Oil globules. C. Fine granular matter. D. Crystals of cholesterin. E. Gran- 
 ular cell. F. Blood corpuscles. G. H. Pus cells, i. Inflammatory globule", of 
 Gluge. 
 
 become more fluid as the cysts grow. The fluid in com- 
 mon ovarian cysts is of a grey, yellow, or brown color. It 
 may be limpid as pure water, or filled with solid bodies as 
 not even to be translucent. Usually it is more or less 
 viscid. Its specific gravity will therefore vary much, but 
 
336 
 
 MEDICAL AND SURGICAL OYNiECOLOQY. 
 
 itrt reaction is always alkaline. Generally ovarian fluid 
 does not coagulate Hpontaneously, but by bein^ boiled the 
 oont(>nts are more or less completely turned into a solid 
 mass. It possesses a remarkable degree of resistance to 
 decomposition, formed elements being sometimes preserved 
 in it for weeks. As a rule, ovarian fluid is full of a variety 
 of formed elements, red blood corpuscles, epithelial cells, 
 nuclei, pigment granules, finely granular globular bodies 
 like lymph corpuscles or colorless blood corpuscles, pus 
 corpuscles, spindle-shaped cells, and crystals of cholesterin 
 and of indican. 
 
 2. Proliferating papillary cystoma is not nearly so 
 common as the glandular, being found in only one out of 
 
 fit;. 99.— Papillomatous ovarian cyst. (Museum of the College of I'lij'sicians anil Surgeons.) 
 
 ten ovariotomies, nor does it acquire such large dimen- 
 sions. Tlu^y contain a comparatively small number of 
 secondary cysts. From their inside spring dendritic or 
 cauliflower-shaped growths, called papilloraata, whicli may 
 entirely fill the secondary cyst in which they grow and 
 break tlirough its walls into a neighboring cyst; or they 
 may perforate the wall of the primary cyst and cover the 
 outside of the ovary and neighboring parts. They may 
 
DISEASES OP THE OVARIES— NEOPLASMS. iiiil 
 
 ovon pcnotrato tho uterus, blnddor, roctum, or otlu^r visoorn, 
 HO ns to form oiui masH with tlicm. The paijilla' nm^(> in 
 ni/iO from that of a poa to that of a small oraiij^fc. They 
 aro Hossih^ or pt'(hinoulatt'(l, and may bo white, dark red. 
 or black. Tho interior of a papillary cyst is usually lined 
 with ciliated epithelium, and the contained fluid not viscid 
 or colloid, but of more watery consistency. This kind of 
 tumor is often bilateral, and its development is much 
 slower than that of the glandular variety. It is ()ft(Mi nr- 
 compani(^d by ascites. 
 
 Mixed proliferating cysts. In one and the same cyst 
 some cavities may be of the glantlular typ(% others of tlie 
 papillary, indi(^ating that there is no radical diU'ercMice 
 between the two varieties, the glandular variety being 
 built up of the epithelial walls which center into the forma- 
 tion of the ovaries, the papillary from its conn(>ctive tissue 
 mainly. 
 
 Origin of proliferating cysts. There is still a con- 
 siderable divt^rsity of opinion in regard to tln^ origin of 
 these cysts. Microscopical examination has shown that 
 both the glandular and tlu^ papillary variety may devi^lop 
 from a (Jrnatian follicle. Another sources may be the 
 germinal epithelium, which in some ovaries, even of 
 adults, forms pouches extending into the stroma of the 
 ovary. Some claim that the papillary cystomata are de- 
 veloped from remnants of the Wolffian body growing into 
 the ovary from the hilum. The source of the glandular 
 variety is by some thought to be a degeneration of the 
 tunica intima of the arteries in the ovary. 
 
 3. Dermoid cysts. These cysts vary greatly from any 
 already described. The internal surface is covered with a 
 nu'.mbrane which looks like skin and has a similar struc- 
 ture. Upon the surface of the derma are papilk-e, anil 
 hairs are inserted into hair follicles occasionally provided 
 with a sebac(H)Us gland. The hairs, whether inv or im- 
 planted, are long, and tawny in color, agglutinated 
 
338 
 
 MEDICAL AND SURGICAL QYNJJCOLOOY. 
 
 to^(>tlu«r by Hc^mcoous mnttor nnd somotimos rolK^d into 
 littlo ImiIIh. Sebum n^Hembliii^ tlu< V(*rnix caH'Hwa, jMirtly 
 tillH tlu' cavity, and ofton forniH Hmall iHolatod niaHHCH. It 
 is sonu'timivs oily in consiHtoncy, and contains many 
 (4)itliolial c(*11m, (rholi^Hterin crystals, and fatty acids. T(H<th 
 
 and bones have been 
 found in these cysts. 
 The bones are in- 
 sorted in tlie wall, 
 and are more or loss 
 covered by the der- 
 mic layer. Thoyare 
 irregular in shape, 
 usually flat, and 
 formed of compact 
 tissue. Cartilage is 
 sometimes present 
 in small patches. 
 Tho teeth project 
 into tho cavity, and 
 are often loosely in- 
 serted into alveoli 
 lormed of bony de- 
 bris. As many as 
 one hundred teeth 
 have been found in 
 one cyst. Unstriped 
 muscle fibres have 
 been found in the 
 
 Fn;. loo.— Dermoid cyst, sliowiiiK pl.ites of bones and dermic laVOr. CaSOS 
 large qll.^ntities of long tawny hair. 
 
 are quoted where 
 striated muscle fibre and nerves distributed to the teeth, 
 have been found. A most remarkable case is reported 
 where the cyst, besides skin, hair, and teeth, contained a 
 body which resembled an eye, with a species of convex 
 cornea, and epithelium like that of the retina. There was 
 
DISEASES OP THE OVARIES— NEOPLASMS. I}|}U 
 
 also n mucous momhrano similar to that of tl'.^ intostiii^H 
 and stomach, and cncophah)id ucrvi^ substatico. 
 
 Oviijin. Tho (lucstiou of the origin of ('crmoid cysts 
 is one of tho most obscure points in gtMiend pathoh)gy. 
 Various theories have been put forth. It has been 
 ascribed to extra-uterine pregnancy, to diptogenesis by 
 fojtal inclusion, and to parthenogenesis duo to a pro- 
 liferation of germinating epithelial cells. The theory of 
 impaction, accortling to Pozzi, is, on the whole, the most 
 satisfactory. According to this view, during intra-uterino 
 existonee certain portions of the blastoderm become im- 
 pacted by pressure within the tissues, and develop there 
 later, giving rise to an irregular formation of the normal 
 tissues. The outer surface of a dermoid cyst is, as a rule, 
 of a dull gray, or greenish color, with orange or ochre 
 colored patches. They are small, or of nu'dium si/e, 
 rarely exceeding in size an adult head. Commoidy but one 
 ovary is affected, but two or three cysts may develop in 
 tlu^ same ovary. A dermoid cyst may form adhesions and 
 ruptuni into another organ, or on the surface of tlu^ body. 
 Tf it opcMis into tlu^ bladder, hairs may be elimiimted with 
 thi^ uriiu>i. A dermoid cyst in one ovary may be combined 
 with a proliferating myxoid cystoma in the other. 
 
 Etiology of ovarian cysts. Little or nothing is known 
 about the circumstances which cause their development. 
 They are met with at all ages. Simple cysts have been 
 found in the ovary at birth. Even in young chikln^n 
 multilocular cystomata have been found. Commonly 
 however, they appear during the period of greatest sexual 
 activity. Single women are proportionately more liable 
 to the disease than married. 
 
 4. Broad ligament cysts. Broad ligament, or, as 
 they are sometimes called, parovarian cysts, are net in 
 reality cysts of tho ovary, being anatomically s(^parate 
 from it, but are best described in connection with tho 
 latter, being surgically and clinically closely connected to 
 
340 
 
 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 thorn. Broad lignmoiit cysts nro much rarer thnii ovarian 
 cysts, and. as a rule, arc monocystic. Commonly they do 
 not oxcood the size of a pregnant uterus at six months 
 gestation, out exceptionally they may become enormous. 
 As a rule, the wall is so thin as to be translucent, but in 
 exceptional cases, the cyst may look like a uterine growth, 
 
 on account of the thick 
 layer of involuntary 
 muscle fibres. The wall 
 is composed of peri- 
 toneum, a layer of 
 connective tissue con- 
 taining muscle fibres, 
 and but few blood 
 vessels, the absence of 
 which gives it its white 
 color. Its internal 
 surface is smooth, or 
 wrinkled, but has no 
 glandular formation, 
 and is covered \\ith a 
 single layer of epithe- 
 lium. The fluid is normally watery, nearly colorless, and 
 alkaline or neutral. It does not coagulate spontaneously, 
 nor to any extent by heat before adding an acid. Papillary 
 and dermoid cysts may also develop in t le broad liga- 
 ment. As a rule cysts of the broad ligam >nt are sessile, 
 but sometimes the ligament forms a pedicle. They are 
 found during the period of sexual maturity; they grow very 
 slowly, do not impair the health, and give rise to no 
 symptoms except such as are produced by their bulk. 
 
 The pedicle. Whatever the origin of ovarian cysts, 
 ther(^ is one important point in their surgical history, the 
 presence or absence of a pedicle. Ovarian cysts as a rule 
 rise up into the abdomen, and are connected with the 
 uterus by means of a pedicle. In some cases the develop- 
 
 [•'k;. ioi.- Unilocul.ir cyst. (Museum of the College 
 of Pliysici.ans aiu\ Surgeons.) 
 
DISEASES OF THE OVAKIES — NEOPLASMS. Ml 
 
 merit tnkes plncc downwnrd, so thnt the cyst is sitiiiitod 
 betwecni the layers of the broad ligament, more or less 
 close up to the uterus, and accordingly has no pedicle. 
 The pedicle may be long or short, thick or thin, broad or 
 narrow. It always contains the ligament of the ovary, and 
 part of the broad ligament, and, as the tumor grows, the 
 Fallopian tube is drawn in so as to form part of it, and is 
 as a rule both elongated and thickened. The arteries may 
 become as large as the radial and the veins the size of the 
 finger. Besides these structures, lymphatics, nerves, in- 
 voluntary muscle fibres and connective tissue, all forming 
 a bundle covered by a peritoneal sheath, enter into its 
 formation. 
 
 Accidents and complications. 1. Torsion of the pedicle. 
 When the pedicle is long and thin, the tumor from some 
 cause may rotate on its axis. Sudden torsion may lead 
 to gangrene and fatal peritonitis. If it develops slowly, it 
 will cause rodema and hypencmia of the wall, hemorrhage 
 into the wall and cavity, or suppuration. If the torsion 
 continues the whole pedicle may be se\ red. Torsion of 
 the pedicle may involve the intestine and cause its 
 occlusion; on the other hand it may effect a cure, by 
 causing atrophy from diminished blood supply. 
 
 2. Adhesions. So long as the wall is covered with its 
 epithelium it slides freely over the surfaces with which it 
 comes in contact, but when the epitheihim is rubbed off", 
 or covered by inflammatory exudation, adhesions to the 
 surrounding structures or organs are easily fornunl. 
 
 3. Ascites. An accumulation of ascitic fiuid some- 
 times accompanies an ovarian cyst, especially the prolifer- 
 ating papillary variety. 
 
 4. Ilemorrhcuje. Blood, arising from erosion of the 
 vessels, ulceration of the walls, or torsion of the pedicle, 
 may be poured into the cystic cavity, imparting to the 
 fluid a dark red or bn-iwn color. 
 
842 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 Suppuration. Tlie wall of a cyHt may booomo inflamed 
 and tlio contonts chanj^od to pus. Tho suppuration may 
 W" duo to torsion of tlio pedicle, to puncture of the cyst, or 
 to puerperal infection. 
 
 (). liupfnrc. The cyst may rupture and pour its con- 
 tents into the abdominal cavity, when the fluid, if unirrita- 
 ting, may become absorbed. Bloody, ichorous, or purulent 
 fluid, and the contents of dermoid cysts cause more or less 
 violent peritonitis, and very likely death. Rupture may 
 also occur into the intestine, stomach, vagina, bladder, or 
 Falloijian tube, or through the abdominal wall, especially 
 at the umbilicus. 
 
 7. C((lrijic(iti(>n (ind ossifwatioii may take place to such 
 proportions that the whole tumor may be changed into a 
 hard shell. 
 
 8. Cdtircrnus (Icf/rnrrafiou. Proliferating glandular 
 cystoraata and dermoid cysts may become malignant and 
 implicate neighboring organs, and with the formation of 
 metastatic deposits elsewhere. 
 
 Symptoms. The onset is characterized by vague dis- 
 turbances which do not differ from those described under 
 uterine symptoms. They are at first reflex troubles due 
 to congestion and stretching of the appendages, later 
 come symptoms due to pressure on the rectum and bladder, 
 but the latter are often absent. Following these occurs the 
 period of tumefaction, when the abdomen becomes more 
 or less distended, and the general health aff'ected. 
 
 Two stages in the development of cystic tumors can bo 
 recogni'/AMl. In the first stage the tumor is small, is 
 hiddiui in the pelvis, and recognized only by bimanual 
 palpation. In the second stage the tumor has become 
 abdominal and may be felt through the walls. 
 
 Pelvic sUujc. As Boon as the tumor has attained three 
 or four times the size of a normal ovary, it falls into Douglas' 
 cul-de-.sac. Bimanual examination will determine its 
 presence, and its situation and connections, as well as its 
 
DISEASES OF THE OVARIES— NEOPLASMS. 343 
 
 ovarian nature. It is usually hard, bocause of the small 
 size and great tension of the capsule. When it has a well 
 defined pedicle it is very movable. When included in the 
 broad ligament it seems to be one with the uterus, but 
 careful examination will reveal a slight groove between 
 them. Tumors limited to the size of the fist or ftwtal 
 head will probably remain permanently in the pelvis, 
 otherwise they will ascend into the abdominal cavity. 
 
 A Inlom hud shu/c. By palpation a well defined spherical 
 tumor is felt above and laterally, but leas marked below. 
 Irregular shape or protuberances generally indicate a 
 polycystic tumor. Fluctuation may be felt, the degree 
 deixniding upon the size of the tumor and the elasticity 
 and thickness of its walls. Percussion over the tumor 
 gives dulness. Bimanual palpation reveals the uterus 
 anteverted, lying just in front of the pubes, and pushed 
 slightly to the opposite side from the cyst. The cervix is 
 drawn upward and not easily within reach. In some cases 
 the uterus ir.ay be pushed downward, and in cysts of the 
 broad ligament it may be pushed completely to one side. 
 The sound .sometimes will show decided elongation of the 
 uterine cavity. 
 
 When the cysts have grown to a large size the abdom- 
 inal walls will be thinned out, fluctuation will be more 
 readily made out, while towards tht? s'do^ solid masses are 
 often found. Percussion elicits flatness over an irregular 
 spherical area, convex above, and separated from the region 
 of hepatic dulness by a zone of resonance. Pressure on 
 the aorta and crural arteries may cause vascular souflles. 
 
 Menstrual disorders are rather rare. Menorrhagia is 
 often very extensive in follicular cysts of the ovary. 
 Sterility is an unavoidable result when both ovaries are 
 att'ected, but a unilateral ovarian cyst sometimes compli- 
 cates pregnancy. Pressure upon the bladder often pro- 
 duces incontinence of urine, and upon the rectum 
 constipation. When the tumor reaches very high in the 
 
JUJ: MEUICAL AND SURGICAL GYNAECOLOGY. 
 
 jibdomon, tlio inovemonts of tho dinplira^m tnny be 
 st^riously ombarmssod, onusing dyspiuun aiul cyanoHis. 
 
 Sooner or later tlie gt^ioral health becomes rapidly im- 
 l)aired, caused by (ioinpression of the various portifjus of 
 the digestive apparatus, joined with a reflex dyspepsia 
 observed in the course of all utero-ovarian diseases. Com- 
 pression of the ureters, though it may not for a long time 
 cause albumenuria, does cause serious uropoietic disturb- 
 ances, and adds to the malnutrition of the system. Pres- 
 sure upon other organs, causing pain and sleeplessness, act 
 in the same way by adding to the general enfeeblement. 
 'Vhen combined these conditions produce an appearance 
 of ill health and distress to which Spencer Wells has 
 given the name " fascies ovariana." 
 
 Pro(/no!-fis. "When ovarian tumors," writes Spencer 
 Wells, "attain such a size that the general health is 
 affected, the length of life granted to the patient will 
 probably not exceed two years, and these two years 
 usually consist of serious trouble, even of torture and- 
 despair," However, in some rare cases, the course of the 
 disease may be very slow. Unilocular broad ligament 
 cysts may rupture into the peritoneum several times in 
 succession, with quite a long respite after each rupture. 
 On the other hand, proliferous cyst"), after remaining 
 quiescent for a long time, may suddenly take a rapid 
 course. An absolute or relative spontaneous cure is not 
 an impossibility. Intra-peritoneal rupture often brings 
 about the cure of broad ligament cysts. Gradual torsion of 
 the pedicle may, exceptionally, cause atrophy. Death is 
 the ordinary result of cystic development, unless there be 
 surgical interference. Marasmus, peritonitis, and embolus 
 are the three causes of death. Ascites, although not 
 necessarily fatal, is an unfavorable occurrence. 
 
 Papillary cysts tend towards malignancy, and wluni so 
 diagnosc^d, should always make the prognosis very guardinl. 
 (ilandular cysts may also undergo cancerous degeneration. 
 
DISEASES OF THE OVARIES — NEOPLASMS. 345 
 
 Oortnlu clinical symptoms, indicated by sudden develop- 
 ment of n tumor which has already existed for some 
 time, rapid emaciation and cachexia, multiple adhesions, 
 especially in the pelvis, redema of the lower limbs and 
 abdominal walls out of all proportion to the size of the 
 tumor and the amount of ascites present, leave no doubt 
 in such cases. 
 
 Diagnosis. 1. In the pelvic stage. In the early 
 stages of ovarian cysts, it is difficult to distinguish them 
 from other tumors situated by the side of the uterus. A 
 sessile cyst of the broad ligament might be simulated by 
 a ccUulifis or saljnngitis, but a remembrance of the 
 previous symptoms, and the course of the disease, will 
 prevent error. A small pelvic hfematocele shows fluctua- 
 tion at first, but does not give tlie sensation of an en- 
 capsuled tumor, while the manner of its appearance is 
 entirely different. 
 
 K.t'tra-ii ferine pregnancy in tlie beginning has few 
 distinctive symptoms, except those of amenorrluea and 
 congestion of the genital mucous membrane. Later it is 
 characterized by special signs which will be referred to in 
 a subsecpient chapter. 
 
 Retrojlexion of the gravid nterus will be suspected 
 when the signs of early pregnancy are present. 
 
 2. In the abdominal stage. Pregnancy. Error in 
 such a case is a very serious one, and is mo' *^ likely to be 
 committed when there is hydramnios, for then it is diffi- 
 cult to palpate the fcBtus or hear the fojtal heart sounds. 
 It must not be forgotten that amenorrhcua, swelling of tlie 
 breasts, and imaginative sensations of fcutal movements, 
 produced by borborygmus, may exist in a case of ovarian 
 tumor. The diagnosis will be settled only by the rercep- 
 tion of f(Dtal movement, the hearing of the heart sounds, 
 the identification of foetal parts, contraction of tht^ gravid 
 uterus, ballottement, and toward the end of pregnancy en- 
 gagement of the fttital parts. 
 
340 
 
 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 Ascites. Ascites mny simulate a large cyst. In 
 effusion of fluid within the pelvic cavity, the abdomen is 
 more bpread out, less acuminated, and on percussion flat- 
 ness is found in the dependent portions, and tympanites on 
 the uppermost surface of the dome. In a position of 
 lateral decubitus, the fluid gravitates to the side and iliac 
 fossa, while the tympanitic note appears on the opposite 
 side, where it did not previously exist. This displacement 
 of the fluid is very characteristic. In cases where ascites 
 has rapidly developed in connection with an ovarian 
 
 Fig. 
 
 102. — The sh.ided portion shows the are.i of dulness. 
 A. Ascites. B. Ovarian tumor. 
 
 tumor, much difficulty may be experienced in making a 
 diagnosis, but the rapid increase in the size of the 
 abdomen, oedema of the lower limbs, decline of the general 
 health, and the absence of a previously existent tu.nor, will 
 assist in making a correct diagnosis. Another sign to be 
 looked for is mobility of the uterus, which is present in 
 ascites and absent in large cysts. Finally the condition 
 of the heart and liver should not be overlooked, disease of 
 either of which often gives rise to ascites. 
 
 ^uhcrcnldv and cancerous peritonitis. In the first 
 named there will be signs of intestinal or pulmonary 
 
DISEASES OF THE OVARIES —NEOPLASMS. 'Ml 
 
 tuberculosis, and irregularities in the siuipe of the abdomen 
 duo to nieteorism interfered with by adhesions. In th(^ 
 case of cancer there will be tiie presence of irreguh'ir 
 masses in the mesentery and neighboring parts, togetln^r 
 with rapid cachexia. Puncture may be of service in 
 establishing a tliagnosis, but at the present day it is usually 
 omitted. Even when done with the greatest precaution it 
 is by no means a harmless operation. It may bo followed 
 by (effusion of tiuid into the abdominal cavity and fatal 
 peritonitis; or by suppuration of the cyst; or by grave 
 lunnorrhage from wounding a blood vessel in tli'' abdominal 
 wall; or an o^ i^rlying portion of intestine may be punc- 
 tured. If the tumor be of the papillary form, there may 
 be escape of vegetations into the abdominal cavity, and 
 conse(|Ucuit infection of the peritoneum. If none of 
 these accidents happen, the puncture is apt to set up in- 
 tlammatory adhesions, which, if extensive, or of long stand- 
 ing, may complicate the removal of the tumor subsequently. 
 
 Uterine Jihroids. Uterine fibroids, particularly fibro- 
 cystic ones, may simulate ovarian cystomata, but a careful 
 examination under an anjcsthetic, takiui in consideration 
 with the history and symptoms of fibroids, will generally 
 make the diagnosis easy. 
 
 H(vm<itometr(i may be recognized by its situation and 
 special etiology. 
 
 Vesicdl distension has been the source of numberless 
 errors, but may be avoided by the employment of a 
 catheter before proceeding to examine. 
 
 Renul tumors, hydronephrosis, and hyddtidiform ei/sfs 
 have also given rise to mistakes. In such cases the 
 diagnosis may be made by ascertaining whether the tumor 
 is fixed in the hypochondrium, and free inferiorly, per- 
 mitting the hand to be passed beneath it quite far above 
 the pubes; and also by ascertaining whether the intes- 
 tines, especially the colon, are interposed between the 
 tumor and the abdominal wall. Tumors of the liver, 
 
348 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 spleen, mesentery, omentum, and echinococcus, may also 
 give rise to error, which sometimes can only to bo cleared up 
 by coeliotomy. Tumors of the abdominal wall, phantom 
 tumors, tympanites associated with partial contraction of 
 the abdominal muscles, or superabundance of fat in any 
 particular spot, may give rise to difficulty in making a 
 diagnosis, particularly in hysterical patients, but the 
 difficulty may be overcome by examination under an 
 an.nesthetic. 
 
 Treatment. It is scarcely necessary at the present 
 day to reiterate the statement made by all writers, that 
 there is only one form of treatment for ovarian cysts, and 
 that is extirpation. 
 
 McdiciiKil treatment. Electrolytic puncture, injections 
 of iodine and other astringents into the cyst are now 
 regarded as malpractice. It is only a few years since it 
 was the frequent practice to tap the cyst several times 
 before its removal, a proceeding which has been aban- 
 doned by all who recognize its dangers. There may be 
 circumstances under which it may be impossible to per- 
 form ovariotomy on account of the objections of the 
 patient or of the friends; or where the presence of cancer, 
 extreme weakness, or grave vLsceral complications would 
 render an operation inevitably fatal. In such cases tap- 
 ping may be resorted to, to relieve immediate symptoms. 
 
 OVARIOTOMY. 
 
 Ephraim McDowell, of Kentucky, was the first to do 
 an ovariotomy for ovarian cyst, in 180^). The pedicle was 
 left in the abdomen, and a cure followed. Subsequent to 
 this there were isolated cases of bold operations which 
 found no imitators. In America, in 1844, W. L. Altlee 
 commenced a remarkable series of operations which, in 
 1871, reached the number of two hundred and forty six. 
 Ovariotomy can be said to have been thoroughly estab- 
 lished in America after the year 1865. In England, 
 
DISEASES OF THE OVARIES — NEOPLASJIS. M\) 
 
 bi^twooii 1852 niul 185(), Bnkor Brown oporatod iiiiio timcH. 
 In tho yenr 1858 commoncod the remnrknblo cnrcor of 
 Spcucor Wells, nud which wns kept up nlinoat to the time 
 of his death, when he had well passed the thousand. The 
 next prominent figure in ovariotomy is tliat of Thomas 
 Keith, of Edinburgh, who performed his first operation in 
 1,862. On the Continent, the names of Koeberle, Schroeder, 
 Billroth, Martin, and others, are honorably associated with 
 the operation. The introduction of antisepsis into the 
 field of surgery introduced a new phase of existence for 
 the operation. Ovariotomy has now passed from the 
 hands of a few eminent specialists into those of surgeons 
 all over the civilized world. In every capital, city, or town, 
 there are surgeons who, with honor to their art and credit 
 to themselves, successfully perform the operation which, 
 half a century ago, was condemned by the leaders of 
 surgery as being little removed from murder. 
 
 The operation. The patient having been prepared 
 according to the general directions given in an early 
 chapter, she is placed upon the back on the operating 
 table. The incision is made in the middle line, between 
 the pubes and the umbilicus, after the manner already 
 described. On reaching the peritoneum it will be found 
 to vary in thickness. It may be thinned by distension, or 
 thickened by constant irritation or inflammation. When 
 there has been much inflammation, the peritoneum may be 
 a thick highly vascular tissue, which bleeds freely on 
 division. The incision is made in that structure long 
 enough to admit of the extraction of the collapsed and 
 empty cyst without using force. If the tumor is unusually 
 large, or the adhesions abundant or very dense, it may be 
 subsequently enlarged to suit the conditions present. 
 
 Emptying and delivery of the cyst. Whatever be the 
 condition prefcent, it is always best to begin by emptying 
 the cyst, and the best mode in the large majority of cases 
 is by tapping. For a cyst of small size Wells' small cyst 
 
.*}50 
 
 MEDldAL AND SURGICAL OYN^ECOLOdY, 
 
 trocar, nnd for n Inr^o ono Tnit's iuHtrunumt with blunt 
 conical point, may bo used. To prcvont tlio t\scapc of 
 Huid at the side of the trocar, a flat sponj^o wrapped 
 around the point of introduction will suffice. After the 
 trocar has entered the cyst cavity and the walls become 
 fiaccid, large forceps are mad(^ to grasp the cyst wall and 
 pull it steadily but gently out of the wound, keeping the 
 pnrii^tes of the tumor in easy contact with the abdominal 
 parietes. A flat sponge placed between the cyst and tlu^ 
 parietes may be useful in preventing the escape of fluid 
 into the abdominal cavity. Secondary cysts may b(* 
 emptied without removing the cannula from the main 
 (!yst. but whiles this is boing done, tlu^ flngiTs inside the 
 abdomini should make certain that the trocar is not pushed 
 through the main cyst wall. As the cyst is withdrawn 
 the trocar opening is pulled ovt^r the edge of the wound, 
 and as soon as it is clear of the abdominal opening, a fold 
 of the (!yst wall above and below is caught in strong for- 
 ceps. The trocar is now removed, and if the sac has not 
 been emptied sufficnently for its total withdrawal, it may 
 be incised betwet'n forceps, permitting the cyst contents 
 to run down into the ovariotomy pad. 
 
 Adhesions. If, after emptying the cyst as compU^tely 
 as possible, adhesions prevent its biding delivered, the im- 
 pcjrtant step of separating them is to be begun. For 
 separating very soft, tine, and recent adhesions, a sjjonge 
 may be used, the adherent structure being, so to speak, 
 sponged away from the tumor. Adhesions of firmer con- 
 sistency may be dealt with in various ways. If compara- 
 tively recent they may be peeled off with the fingers. If 
 the adhesions are old, fibrous, and thick, they may be sur- 
 rounded by ligatures and divided. During the separation 
 of adhesions the walls of any of the hollow viscera may be 
 torn. Such laceration must of course be immediately 
 closed by suitable sutures. If at any point the connection 
 to the bowel or bladder is so intimate that complete separ- 
 
DISEASES OF THE OVARIES— NEOPLASMS. 
 
 H51 
 
 ntion Houms dnnj^erouH to the integrity of the orjjjau, thou 
 a thin layer of the ndhorent portion of the cyst wnil must 
 be cut off and left behind. 
 
 Tfcdtmt'ut of the pvtUclc. The pedicle has been sub- 
 jected to almost every conceivable surgical treatment. 
 " It has been tied (Mitire, tied in sections, been twisted oft', 
 burnt off, crushed off, cut S([uaro off. cut off' in Haps, left 
 inside, left outside, and has been made to slough oft'." — 
 (Bland Sutton.) 
 
 The extra-peritoneal treatment by the clamp is now 
 permanently abolished, and needs no description. The 
 silk ligature is now almost universally used for securing 
 the pedicle, although strong coarse catgut is used by some 
 
 Fig. 103. — Ligation of pedicle in three sections. 
 
 surgeons. After fully exposing the pedicle, and estimating 
 its size and the position of the blood vessels, a pedicle 
 needle, threaded with stout silk, is passed through the 
 centre, taking care to avoid all vessels. After dividing 
 the silk into two equal parts, the needle is unthreaded 
 and withdrawn. Each division of the ligature, after 
 interlocking it with the other, is tied over its own half of 
 the pedicle, and then returned and tied over the opposite 
 half. 
 
352 MKDUIAL AND 8lIR(4It!AL «YNiK(!OL()<»Y. 
 
 WIhmi tho ixnliclo in vory brond it mny nuiuiro li^nt.ion 
 ill MoctioiiH. TliiH mny bo dono by puHHiu^ tlu* pi'diclt^ 
 iuhhHo, annod with tin oxtra lon^ nilk li^iituro, tlirou^h 
 tho pedioh) ono third distnut from tlio mnr^iii. Tho loop 
 i!\U8 formed in cnught on ono tiii^or und tlio iuhkUo Htill 
 throudod withdrawn, and rooutorod midway botwooa tho 
 last point of ontrancii and tlio oppoHito margin. Tlio 
 podicUo neodUi in again withdrawn and th(^ loo^w arranged 
 HO that thoy will bo of oqual hingth. Tho ligature in 
 divided at tho loops, and after interlocking one with the 
 other, each ligature is separately tied so as to include its 
 
 own section. The ends of the outer 
 ligatures may be reversed and tied 
 around tho opposite sides of tho 
 pedicle. A favorite method for so- 
 curing tho pedicle is that known 
 I'Ki. io4.-staffordshire knot, as tho "Staffordshire knot." The 
 
 pedicle noodle, armed with a silk 
 ligature, is passed through the pedicle and then with- 
 drawn, so as to leave a loop on tho distal side. This loop 
 is then drawn over the tumor, and one of the free ends 
 drawn through it, so that one end is above while the other 
 is under tho retracted loop. Both ends being seized in 
 tho hand, they are drawn through tho pedicle until com- 
 plete constriction is made. 
 
 The pedicle secured, it may now bo divided at a 
 distance from the ligature sufficient to prevent it slipping, 
 and the stump allowed to drop back into tho pelvic cavity. 
 The peritoneal cavity, if necessary, is to bo carefully 
 cleansed, taking care not to overdo it. A sponge on a 
 holder is left in contact with tho stump of tho pedicle 
 until the parietal sutures are introduced, after which it 
 may bo withdrawn, and if it indicates that no hemorrhage 
 is going on, the abdominal wound can be closed. 
 
 Accidents durhu) operation. Mishaps, such as the 
 escape of fluid into the cavity, hemorrhage, or injury to 
 
DISEASES OF THE OVARIES -NEOPLASMS. 352} 
 
 tlu^ viHC(^ni, may occur during tlu^ most. Himplt^ ovnriotoiuios, 
 and tlu^y nro eHptH'-ially fro(iuciit in dilHcult cnsos. It is 
 nocoHHiiry tlu^n^foro for ovory surgoon, to \w suo(H^HHful, to 
 bo nbhs promptly and (>fHci(mtly, to deal with hucIi 
 acuiidiuits, and without such knowUHlge no surgoon shouUl 
 undcrtako an ovariotomy. 
 
 Broad ligament cysts, as a ruhi, grow away from the 
 ligament, pushing aside the ovary and tube, and o-^ca- 
 sionally tht^y exhibit a well marked pedicle. Sometimes, 
 however, they may grown downward, widely separating the 
 layers of the broad ligament, and stretching out the tube 
 and ovary over their walls. Adhesions are rare, but spon- 
 taneous rupturt^ is not infrequent. These cysts wen^ onco 
 r(Mnoved by tapping or aspiration, and their innocuous 
 luiture and slowness to rt^till are great inducements to use 
 that kind of treatment, but since it has been discovered 
 that some of them are papillary growths, and the radical 
 operation in most cases easy and safe, extirpation is pre- 
 ferred. Thiur removal, when there is a pedicle, is to be 
 a<;complish('(l the same as in ovarian tumors. 
 
 In some rare cases, when the cyst grows between tlie 
 layers of the broad ligament, removal may be attended 
 with considerable difficulty. Here there is no pedicle, 
 and the base of the cyst lies deep in the pelvis. The 
 growth in these cases must be dissected out between the 
 layers of the ligament. Beginning on the side next the 
 uterus the jieritoneal investment is opened, and the wall 
 of the cyst exposed. The finger pushed into the cellular 
 tissue separates the cyst from the ligament, bleeding 
 vessels being caught up by forceps. Step by step the 
 process is continued until the cyst is completely enucleated 
 from its bed. The two flaps representing the layers of the 
 broad ligament may, according as seems best at the time, 
 bo left untouched, or united by suturing; or after ligation 
 in section, its upper portion may be cut .way and the 
 peritoneal structures turned in and sutured. 
 
354 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 Incomplete operations. Tlio presence of Hrm general 
 ndhesious of nu intrn-lignnieiitous cyst which will not 
 permit of its being enucleated without extreme shock and 
 loss of blood, or the sudden collapse of the patient in the 
 middle of the operation, may determine the surgeon to 
 ccmclude it without total removal, or as rapidly as possible. 
 In such cases the cyst may be emptied, and after beiii^; 
 drawn up into the wound, as much of the sac as possible 
 may be excised, and the remaining portion sutured in the 
 lower angle of the wound and drained by gauze pnc';iiig. 
 The method of .- raining by an openiiig through the vagina 
 presents many advantages, especially in the c;ase of sup- 
 puratii\g cysts firml)' adherent to the floor of the pelvis. 
 
 SOLID TUMORS OF THE OVARY. 
 
 Under this heading is included Jihroma, sdrcorna, 
 and cjn'th: lioma or ctu'ciuoiiui. 
 
 Fibroma. Fibroids of the ovary are rare. They do 
 not form circumscribed new growths like flbroids cf the 
 uterus, but seem rather to be a kind of fibroid degener- 
 ation of the organ, and so uniformly hypertrophied that 
 its shape and relations are not .xltored. As a usual thing 
 they are small, not larg(^r than a hen's egg or an orange, 
 but they may n^ach largCi proportions. They are hard in 
 ct)usistency and have a mammillaied surface. They 
 usually have a pedicle, and are free from adhesions be- 
 cause of the .ascites which they produce. They may 
 become cystic, due to dilatation of the lymph spaces in tlie 
 connective tissue — the so called (/codes— and filled with a 
 coagulable serous fluid. 
 
 Siimj)f<)ms. The symptom which usually first attracts 
 notice is ascites, caused by the excessive mobility of the 
 tumor. When this symptom is absent, the tumor may 
 escf^pe notice, or may accidentally be discovered by 
 ptteiiiion being drawn . i the patient, owing to menstrual 
 disturbances. li is alraost impossible to diagnose it from 
 
DISEASES OF THE OVARIES— NEOPLASMS. 355 i 
 
 1' ;. 
 
 a pedu ^ulntod fibroid of tho uterus. Tlie trontmont con- 
 sists in its removal by vaginal or abdominal hysterectomy. 
 Sarcoma. This neoplasm is of rare occurrence. It 
 may be primary, or it may develop secondarily in an 
 ovarian cystoma, and is often bilateral. It forms a pink 
 tumor, ranging in size from that of a smjdl orange to that 
 
 of an adult head. It is globular or oval, has a smooth ii, 
 
 surface, and of varying consistency according to structure. ji 
 
 Spindle-celled sarcoma is the most common variety, but 
 
 round celled and mixed celled sarcomata are also found. fi 
 
 From a clinical point of view <^hese tumors are of great 
 malignauviy, and the symptom^: are ihose of a rapidly 
 
 developing malignant tumor. Ascites . .. ^ i 
 
 is always present and cachexia rapidly , ^(^j^^ '^^C^^'^ ^ 
 
 appears, features which distinguish it 0f^^ ^<^B>^\k -- [ 
 
 from fibroma. ^"^T^^, ,^ f 
 
 Epithelioma or carcinoma. If '^^^JfcTv^^^^ ® 
 secondary cancerous degiMieration of ^^^l^^'^ ** ''^ ^■^ 
 cysts is excluded, primary cancer of ^i^r^-^^^v^ 
 the ovary is very rare. It may affect 
 the young as well as the old, and is '''"=• i"5- Spin.iie-ceiie,i s.-»r- 
 
 •' '^ coma of the ov.iry. 
 
 apt to be bilateral. Two principal 
 
 anatomical forms are described; one, a diffuse infiltratifui 
 of the ovary, originating in the (epithelium of the follieU'.s 
 of Pfiuger's ducts; the other a superficial !li>velo[)ment 
 from germ epithelium. In the former, the ovary retains 
 its shape fo^^^ a long time, with the exception that its 
 surface becomes nodular. It may attain the size of an 
 adult head, and as it increases in size the pedicle and 
 broad ligam nt become infiltrat(>d. In the latter variety 
 a dendritic growth appears on the surface of the ovary, 
 whieli, in the later stage cannot be distinguished from 
 papilloma of the ovary. 
 
 Ascitic fli. 'd, possibly tinged with blood, is character- 
 istic of this disease, and the other symptoms will be 
 similar to those of sarcoma. The diagnosis is based upon 
 
 ..<!»> i 
 
 ■i/.^ 
 
 :'■? 
 
356 MEDICAL AND SUROICAL GYNECOLOGY. 
 
 tho blo(Hl tinged ascites, infiltrntion of tho broad ligament, 
 upon the existence of nodules about the rocto-uteri)io 
 cul-de-sai-. and upon the rapidly appearing cachexia. 
 When seen early, tho treatment consists of performing 
 oophorectomy; later the treatment can only be palliative. 
 
 CHAPTER XXX. 
 
 ECTOPIC GESTATION. 
 
 By this term is generally understood development 
 of the impregnated ovum outside the normal uterine 
 cavity. No entirely satisfactory conclusions have yet 
 been reached regarding the cause of this form of preg- 
 nancy. The chief difficulty lies in the fact that it has not 
 yet been determined at what point of the female genital 
 tract normal impregnation of the ovum takes place, and 
 until this question is settled, the primary question, 
 whether extra-uterine fcBtation is an abnormal ectopic 
 impiegnation, or is simply a detained impregnated ovum, 
 must remain unanswered. 
 
 Etiuluiji). It is claimed by many that the seat of 
 coalescence of the male and female elements is normally 
 in the Fallopian tubes, and if such be admitted, it can 
 readily be seen how a variety of causes m _, operate to 
 detain the ovum in the tube. The most frequer . condi- 
 tions named as tending to bring about ectopic gesf.ition. 
 are : — Adhesions of the ovaries and tubes, the rt suit jf 
 peri-salpingitis; loss of ciliated epithelium; ttoxioii of ^he 
 tubes; dilatations and diverticula; constrictions from in- 
 flammatory changes; and polypi of the tube, closing its 
 lumen like a ball valve. Uiitil recently it was the common 
 belief that the ovum might, after fecundation, develop 
 primarily in tho tube, within a Graafian follicle, or in the 
 peritoneal cavity. Modern research, and the advantages 
 for observation which early cceliotomy has given in such 
 
ECTOPIC GESTATION. 357 
 
 cases, hnve chnngocl to a considerable extent the views 
 once held. At the present time the weight of opinion 
 leans towards accepting two primary forms of ectopic 
 gestation, the tubal and ovarian, although niany able 
 writers assert that all ectopic gestations are originally 
 tubal. 
 
 C](iss{Jic((fion. Ectopic gestation may be divided into 
 2)rini((rij and scvondary forms. The primary form may 
 be thus classified: — 
 
 id, Tubo-uterine or interstitial. 
 6. Isthmial. 
 c. Ampullar. 
 2. Ovarfan 
 
 In tubal pregnancy when the fertilized ovum vlevelops 
 out near the fimbriated extremity it is called (impulhir; 
 when at the inner portion of the tube it is called isthmUd; 
 and when in that part of the tube which traverses the 
 uterine walls, it is designated interstitial or tuho-uterine. 
 
 Tlie secondary forms of ectopic gestation are derived 
 from the primary. The tubo-uterine or interstitial may 
 rux)ture into the uterus and be followed immediately by 
 expulsion of the fijutus, or it may go on to full term and 
 be delivered in the natural way. It is more likely, how- 
 ever, to rupture into the abdominal cavity, or into the 
 broad ligament. In the isthmial form, the rupture occurs 
 into the abdominal cavity, giving rise to a secondary 
 abdominal pregnancy; or into the broad ligament, forming 
 extra-peritoneal broad ligament pregnancy. The ampullar 
 form of tubal pregnancy gives rise to secondary tubo- 
 ovarian. abdominal, or broad ligament pregnancy. The 
 ovarian form gives rise to tubo-ovarian, or abdominal 
 pregnancy. The secondary forms thus derived from the 
 primary may be classified as follows: — 
 
 (I. Uterine. 
 1. Interstitial. { h. Broad ligament, 
 e. Abdominal. 
 
358 MEDICAL AND SURGICAL GYN-ECOLOGY. 
 
 a. Tubo-ovariaii. 
 2. Ampullnr. \ h. Abdominal. 
 
 ii. latlitnial. 
 i. Ovarian. 
 
 Broad ligament. 
 
 (1: Abdominal. 
 
 I). Broad ligamont. 
 
 (I. Abdominal. 
 b. Tubo-ovarian. 
 
 Tubal pregnancy. In the first week after fecundation 
 the tube begins to thicken, which is mostly due to ex- 
 cessive vascularization, and not, as in the case of the 
 pregnant uterus, to any great increase in its tissue elements. 
 As pregnancy progresses, the wall of the tube becomes 
 thinnod and stretched, until in some cases it appears as a 
 thin transparent membrane, composed only of an attenu- 
 ated stratum of muscle covered with peritoneum. The 
 dovelopraeat of the fcetal membranes is the same as in 
 intra-uteriiie pregnancy, except that the placenta is largely 
 foital in its origin. During the first four to six weeks, the 
 abdotninal ostium of the tube becomes hermetically sealed. 
 Ui'til the foetal membranes are well formed, the chorionic 
 villi have but a feeble hold upon their points of attach- 
 ment, and may be easily separated. Should this occur 
 during the first two or three weeks of pregnancy, it will 
 probably give rise to no serious di.scomfort, but, if later, 
 the accompanying hemorrhage may cause rupture of the 
 tube, followed by death of the motlier. 
 
 If the ovum continues to grow, the point of attachment 
 of the placenta is one of great importance to the mother. 
 If it is implanted in the upper wall of the tube, she is in 
 constant peril, for rupture means almost certain death 
 from hemorrhage, there being no counter-pressure to con- 
 trol the lacerated or detached placenta. If implanted on 
 the floor of the tube the chances for rupture are decreased, 
 and when rupture occurs the dangers from hemorrhage are 
 diminished, owing to the placenta being pushed downward 
 against the resisting pelvic floor. Occasionally the ovum 
 
ECTOPIC tlESTATlON. 359 
 
 is lightly attnclu'd in tlu^ finipulUir oxtnMiiity of the tubo, 
 aiul is extruded into tlio nbdoiniiml caxity without rupture 
 of the tubal wall. This extrusion is known as fiilxti 
 abortion. 
 
 Tubo-uterine, or interstitial gestation. In this typo 
 the museular fibres of the uterus undc^r^othe same changes 
 as in normal pregnancy. Rupture is almost inevitable, 
 but it does not occur as early as in the tubal form. The 
 foetus occasionally escapes into the uterus, to be at once 
 expelled, or to go on to full term. Rupture however in 
 this case most frequently occurs into the abdominal cavity, 
 followed by profuse hemorrhage, wliich u.sually terminates 
 the patient's life. 
 
 Rupture of the sac. Tlie time at which this may occur 
 depends uj)on the location of the placenta, and to a certain 
 extent upon the attachment. In tubal pregnancy, primary 
 rupture occurs usually between the second and four- 
 teenth weeks. The rupture is owing to thinning of the 
 walls of the tube beyond their limits of elasticity by 
 hemorrhage or by gradual enlargement of the embryo; or 
 it may occur as the result of traumatism. If the patient 
 survives the primary rupture, the foetus may continue to 
 develop, either burrowing down between the layers of the 
 broad ligament or extending upward into the peritoneal 
 cavity. The blood, if poured out into the peritoneal cavity, 
 will usually be absorbed: if the hemorrhage occurs between 
 the layers of the broad ligament, it constitutes an extra- 
 peritoneal pelvic hematocele. After the twelfth week the 
 sac is liable to secondary rupture at any time up to term, 
 and here again the situation of the placenta is of the same 
 im])ortance in the prognosis as in the primary ru^iture. 
 
 The foetus. The question as to the possibility of life 
 for the foetus is influenced by the location of the pla'UMita. 
 In the tubal variety, the most favorabh* attachment of the 
 placenta is on the floor of the Fallopiat' tubii, ns there may 
 be slight if any disturbance of the fiBtal circulation if the 
 
.%0 MEDICAL AND SURGICAL GYNJICOLOGY. 
 
 rupture be in the superior wnll, and the child may thus ^o 
 on to full term. In ectopic gestation, even should the 
 child be delivered alive, it is often deformed, puny, and 
 rarely survives more than a day or two. Should the 
 mother survive rupture, and the embryo die, it may be 
 completely absorbed as it lies in the abdominal cavity, up to 
 the second month; after that it either undergoes mnniniiji- 
 cation, calcijicdtioii, or is converted into adipocere, or it 
 decompoiics. 
 
 Mummification is similar to that change which bodies 
 undergo in a dry atmosphere. The tluid constituents are 
 absorbed, and the soft tissues become leathery, or parch- 
 ment like. In other cases the fatty elements are converted 
 into adipocere. Either the mummified or the adipocere 
 foetus may become partially or wholly calcified, and is then 
 known as a lithopedian. The foetal mass may remain for 
 a long time in the abdominal cavity, but should pyogenic 
 organisms gain access to the sac from a neighboring organ, 
 the fcBtus will be converted into a putrid mass which may 
 be discharged into the rectum, vagina, or bladder. 
 
 Symptoms. All the symptoms of normal pregnancy 
 may, though not always, be present. In some cases, in- 
 stead of amenorrhoea there will be profuse metrorrhagia 
 with expulsion of some bits of decidua. This symptom is 
 not to be confounded with membranous dysmonorrluBa, 
 already referred to when sjieaking of that disorder. Pain 
 is variable, in some cases it is almost constant, and in otluM's 
 abs(>nt. When present before rupture it may be sharp 
 and lancinating, or a dull heavy aching. Changes occmr 
 in the external genitals similar to those in normal preg- 
 nancy, together with softening of the cervix. On exam- 
 ination, the Fallopian tube of one side will be found 
 enlarged, and, if far advanced, will be forced from its 
 normal position. ShouUl pregnancy have advanccnl to the 
 tliird or fourth month, a tumor with a well defintul area of 
 dullness on the anterior abdominal wall may be made out 
 
ECTOPIC (IKSTATION. 861 
 
 by percussion. By va^innl oxniniiuitioii tlu^ tumor will bo 
 found Intornl, unci jit one side of tlie uterus with u sulcus 
 between them. 
 
 Rupture. The symptoms of rupture are very pro- 
 nounced. A patient in prmMously good health, complain- 
 ing^ only of some mild form of disturbance, and possibly 
 with some of the earlier symptoms of prej:;nuncy, is 
 suddenly seized with severe lancinating, cutting, or 
 agonizing abdominal pain. If the hemorrhage is extensive, 
 she may fall almost as unconscious as if struck a blow. 
 Soon tliere are the usual symptoms of severe intc^rnal 
 hemorrhage, indicated by a rapid or almost imperceptible 
 pulse, quickened jerking respiration, air hunger, vertigo, 
 nausea and vomiting, and dimness of vision. These 
 symptoms soon merge into those of profound slioc!k, the 
 extremities becoming cold and clammy, tlu^ skin pal(% the 
 conjunctiva; pearly, and the face drawn. Death may 
 follow at once, or it may be delayed for a day, or even 
 longer. In some cas<^s the hemorrhage ceases for some 
 time, to begin some days later and then prove rapidly 
 fatal. 
 
 When rupture occurs into the broad ligar nt the 
 initial attacik is similar, but the subseciuent symptoms are 
 not so urgent, and the hemorrlmge will soon cease from 
 its own pressure. Should tlu> embryo die there may be 
 no further trouble, but often the fditus continu(^s to 
 develop, and sooner or later a secondary rupture occurs. 
 
 In those rare cases which go on to full term, labor like 
 pains, closely resembling normal labor, come on, and may 
 continue for hours, or even days, and then c 5ase. During 
 this time escape of blood, and of portions of the decidua 
 occur in a majority of cases. 
 
 When the patient survives rupture the sharp labor like 
 pains subside, the breasts diminish, the tumor decreases 
 rapidly in size, and she may regain her health in time, 
 
ii62 MEDICAL AND SURGICAL QYNiECOLOGY. 
 
 absorption, or one of tlio othor changes tlint rondor the 
 fcEtnl body innocuous, taking place. 
 
 Diagnosis. A careful review of the cliiucal history 
 will often lead to a suspitaon of the condition. A multi- 
 para, who, perhaps, has not borne any children for some 
 years, and probably has had in the meantime an attack 
 of salpingitis and pelvic peritonitis, develops the early 
 symptoms of pregnancy. There will be more or less 
 dull ovarian pain, which continues until it terminates in 
 the paroxysms of ruptuns and which, if not fatal, is 
 followed by marked auiemia. A bimanual examination, 
 taken in conjunction with this clinical history, will point 
 certainly to the nature of the pregnancy. 
 
 A rctrovcrfcd j/rdvid uterus may give rise to mislead- 
 ing symptoms, but a careful vaginal and rectal palpation 
 will make out the eidarged fundus. 
 
 Ovarian tumors and cnlarficmoit of tlic Falloju'an, 
 tubes associated with intra-uterine pregnancy, may lead 
 to error, but the fever which accompanies pyosalpinx in 
 the majority of cases will mark the difference. If it be 
 impossible to arrive at adefinito conclusion, it is justifiable 
 to recommend exploratory coeliotomy. The ru])fure of a 
 p}jOsali)in.r may be mistaken for a ruptured tube, but 
 when such occurs, the clinical history is entirely different, 
 the pulse is not so rapid, the temperature rises rapidly and 
 steadily, the patient does not present such marked symp- 
 toms of loss of blood, but shows early signs of sepsis. It 
 can scarcely be expected to differentiate between the tubal, 
 ovarian, and the secondary abdominal form, when anato- 
 mists fail to agree concerning them when the abdomen is 
 opened. 
 
 Treatment. Before rupture. The electrical treat- 
 ment, once so much advocated, has fallen into disrepute 
 on account of the uncertainty of terminating fcetal life, 
 and its dangers to the mother. Nevertheless, as stated 
 before, when speaking of the practical application of 
 
EOTOI'IC GESTATION. .%3 
 
 electric curroritH, its use mny bo couHidorod justifiable 
 when the pntic^it is far removed from skilled hands, or 
 when the patient positively refuses to submit to cdBliotomy. 
 Should this procedure be decided upon, the transmission 
 of the faradic current is accomplished by passing one 
 pole into the rectum or vagina as far as tlu^ site of the 
 ovum, and placing the other on the abdominal wall over 
 the ovary. The full force of a one-celled battery is turned 
 on for a period varying from five to ten minutes. The 
 treatment should be continued daily for one or two weeks. 
 
 Injections of solutions into the sac, such as half a 
 grain of morphia, for the purpose of destroying the foetus, 
 have also been tried and advocated. 
 
 Undoubtedly when a diagnosis has beeii made previous 
 to rupture, the proper course to pursue is the removal of 
 the atfected tube. Cases with a history suggestive of 
 ectopic gestation, and a mass lateral to the uterus detecttHl 
 by vaginal examination, should be operated upon without 
 hesitation. A proportion of such cases may prove to be 
 pyosalpinx or hydrosalpinx, but the error is not a serious 
 one, as in either instance operation is indicated. 
 
 A f finir of rupture. If the patient is seen at the time 
 of, or imnunliately afttM* rupture, the obstetrician must 
 exercise much judgment in arriving at a decision. Should 
 examination make certain that hemorrhage has occurred 
 into the broad ligament, the method of treatment should 
 be an expectant one, the possibility being that the 
 hemorrhage will soon cease, if it has not already done so. 
 Should examination reveal free fluid in the cul-de-sac, and 
 there are no signs of improvement in the patient's condi- 
 tion, intra-peritoneal rupture has doubtless occurred. In 
 such a case operation is indicated, provided there is 
 sufficient vitality left for it to be undertaken with any 
 degree of success. In any case attention should bo 
 directed towards arresting the hemorrhage, overcoming 
 the shock, and sustaining the patient. Injection.:} of 
 
364 
 
 MEDICAL AND SUKOICAL OYNiECOLOOY. 
 
 strychnino niul brnndy may bo pfiven hypodormationlly, 
 and infuHJoii of normal Halt Holutioi injocti'd into the radial 
 artery or pectoral region, if tiie necessary appliances are at 
 hand, or if not, into the rectum in the form of an enema. 
 
 Ojwrdfion. After opening the abdomen clots should 
 be turned out as rapidly as possible, and the ovarian and 
 uterine arteries caught either with forceps or the fingers. 
 If while clearing the pelvis fresh blood wells up, the 
 bleeding points must be exposed, and hjemostatic forceps 
 applied. Having controlled active hemorrhage, the rest of 
 the operation, if pregnancy has advanced as far only 
 as the first or second months, may consist merely of 
 salpingo-oophorectomy. If. however, gestation has further 
 advanced, attempts at removal of the placenta are ex- 
 ceedingly hazardous, and the hemorrhage following its 
 dislodgement may defy oontrol. No means further than 
 those necessary to save life at the time of the operation 
 should bo undertaken, and consequently the best course to 
 pursue in such cases is to check the hemorrhage, cut the 
 cord close to its placental origin, and leave the placenta 
 undisturbed, to be removed by absorption or by subsequent 
 operation. Drainage should not be employed as it in- 
 creases the danger of sepsis. 
 
 After rupture. Should there be a history of previous 
 rupture occurring at the first or second months after 
 gestation, operation should not be performed unless the 
 foetus has ccntinued to grow. If the life of the foetus has 
 not been destroyed at the time of rupture, the operation 
 should be performed as soon as the patient has recovered 
 from the primary rupture. As the dangers of operation 
 greatly increase as the pregnancy advances on account of 
 the development of the placenta, the earliest date possible 
 should be selected. If the ijregnancy is in the early 
 weeks, the operation may be no more difficult than 
 salpingo-oophorectomy for hydrosalpinx, and is somewhat 
 similarly ijerformed. If pregnancy has further advanced. 
 
PELVIC H/EMATOCELE. 3()5 
 
 and ndlu'Hioiis Imvo fornuMl botwcnni tlw pfostntiou hao iiiid 
 tin* ndjdoi^iit viHc-cirii. or if it in a broad li^ainoiit i^ostatioii 
 with tUv placHMita firmly implanted on tlu^ polvic fioor, tho 
 opi^ration bccomoH nxciHMlin^ly difficult. Tho adhosions 
 should be disHeetod off' oarefully, bleeding pointH ligated, 
 and the Hac enucleated in the ordinary way. 
 
 Kvdcudtlon of the ija^tdtlon Xdc fln'oiKjIi flic ViKjiiKt. 
 After carefully examining tlui mawH and deciding upon 
 the most accessible point for evacuation, usually in tho 
 fornix, a pair of blunt-pointed forceps are thrust into the 
 sac, and with the blades opened are partially withdrawn 
 whih^ the sac is being steadied from above. The embryonic 
 debris is evacuated with the finger inserted through tho 
 opening, after whicih the sac may be washed out with a 
 weak solution of bichloride, and afterwards packed with 
 gauze. 
 
 CHAPTER XXXI. 
 
 PELVIC HyEMATOCELE AND PELVIC H/EMATOMA. 
 
 The mere effusion of blood (intra-pelvic hemorrhage) 
 into the pelvic cavity should not be confounded with 
 hajmatocele, the term pelvic luumatocele being reserved for 
 encysted collections of blood. When tlm blood effused 
 and so encapsulod lies within the i)eritoneal cavity, it is 
 termed intra-pcritoneul Itwrnatocclc, or simply pelvic, 
 h(t'm<itocelc. When tho blood is spread out below the 
 serous membrane, within the broad ligaments, it is called 
 cxtrd-pcritoncdl luenuitoei'le or simply [wlcie hcrinatonid.. 
 
 PELVIC HEMATOCELE. 
 
 Etiology. The effusion of blood into the pelvic cavity 
 may arise from tho tubes at tho regular menstrual period, 
 the hemorrhage taking place from its distal end, and 
 generally presupposes the existence of salpingitis. In 
 such a case the amount effused may bo comparatively 
 
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36() 
 
 MEDICAL AND SURGICAL OYNiECOLOGY. 
 
 small, and may undergo absorption, or may become 
 eTioapsuled from inflammatory adhesions. Subsequent 
 tubal hemorrhages may increase the size until the 
 hiematocelo may attain considerable proportions. The 
 most common origin is recognized by all to be the early 
 rupture of an extra-uterine pregnancy, and by some it is 
 stated to be the only one. Other causes are assigned, such 
 as rupture of varicosities of the utero-ovarian plexus, 
 disorders of ovulation, abortions in connection with 
 peritoneal adhesions, hematosalpinx or ovarian hwrnatoma, 
 
 atresia of the cervix or vagina, 
 and the rapid evacuation of 
 the uterus for hjematometra. 
 
 The tumor is usually situated 
 in Douglas' cul-de-sac. At the 
 outset the blood is liquid and 
 for.ns a sort of lake, but the 
 cyst, however, is rapidly formed, 
 a..d is then entirely separated 
 from the mass of intestines. 
 In this way it is often difficult 
 to distinguish the arch formed 
 by the new membranes from 
 an uplifted peritoneum. The uterus ia pushed towards the 
 sympliysis .^nd the sac is adherent in front to its posterior 
 wall, and to the agglutinated intestines which lie upon it. 
 The sac contains a mass of coagulated, or syrupy stMni- 
 liquid blood, according to the length of time the lesion 
 has existed. Even in cases where there is reason to 
 suspect tubal pregnancy as the cause, it is not usual to 
 find any piece of the fcBtus, as it usually disintegrates and 
 is absorbed. 
 
 Symptoms. The appearance of hematocele is usually 
 associated with symptoms characteristic of its production, 
 such as those connected v/ith the uterine appendages, or 
 ectopic gestation. It is seldom that the effusion of blood 
 
 Kic. io6. — Retro-uterine haimatocele. 
 U. Uterus. R. Rectum. A. Blood- 
 clot. 
 
PELVIC H HEMATOCELE. 367 
 
 is noc ushered in by some decided disturbance. In the 
 most severe cases, there mny bo those which have been 
 mentioned as cliaracterizing ruptured tubal pregnancy. 
 In less severe cases there may only be local pain, and a 
 sensation of weakness, accompanied by an increase in the 
 size of the abdomen; or the oozing of blood may be so 
 insidious that the syra^)toms may be imperceptible. On 
 making . iginal examination, a iluctuating tumor will 
 be felt in i-ouglas' cul-de-sac which pushes the uterus 
 upward so that the cervix is reached with difficulty, and 
 when felt is found flattened against the pubes. By 
 bimanual examination, the uterus can be outlined and 
 seems to be incased in the mass which fills, or more than 
 fills the pelvis. 
 
 The course of the disease is essentially chronic, but 
 successive attacks at times occur. In the most favorable 
 cases, the patient is unable to walk for many months, and 
 is exposed to repeated attacks of peritonitis, during which 
 the tumor is subjected to change of size, and finally dim- 
 inishes by degrees. Instead of this the tumor may remain 
 for an indefinite period, with but little change in the 
 syrupy chocolate colored contents. Suppurative inflam- 
 mation may set in, and the mass may be converted into an 
 abscess cavity, which increases its size and softness. Per- 
 foration into the abdominal cavity is rare, but perforation 
 may take place into the rectum, by which the whole mass 
 may become evacuated and complete recovery follow. 
 
 Diagnosis. The sudden appearance of a retro-uterine 
 tumor coinciding with the phenomena of internal hemor- 
 rhage is almost pathognomonic. It might be mistaken 
 for a ruptured pyosalpinx or a retrovertod gravid uterus, 
 I'Ut the diagnosis of these conditions has already been 
 referred to in the chapter on ectopic gestation. Ovarian 
 cysts and uterine fibromata have nothing in common with 
 hematocele, their manner of appearance and course are 
 entirely different. 
 
368 MEDICAL AND SURGICAL GYNJICOLOGY. 
 
 Treatment. Active interference is justified only by tl\e 
 appearance of accidents which may endanger the life of the 
 patient. If seen at once, absolute rest in bed is demanded, 
 and ice may be applied over the lower abdominal region. 
 Antisepsis of the vagina is to be attended to, to avoid all 
 danger of infection through that channel. It is best to 
 leave the disease to itself, so long as it follovrs a regular 
 and progressive course towards absorption. Should such 
 not occur within a moderate limit, or the ])atient'8 life is 
 threatened by compression or inflammatory phenomena, 
 rapid evacuation of the cyst becomes obligatory. 
 
 Incision is preferable to puncture, and the site of the 
 incision is to be determined by the protrusion of the 
 tumor. If it projects plainly into the posterior cul-de-sac, 
 it should be opened through the vagina. By the use of 
 retractors the field of operation is enlarged as much as 
 possible, and an incision is made following the axis of the 
 tumor, care being taken not to injure the ureter by going 
 too far forward in the lateral forviix. The finger in the 
 rectum will serve as a guide in avoiding the intestine. 
 After reaching the %iterior of the cyst, the opening may 
 be enlarged and the contents carefully evacuated with the 
 fingers, or by antiseptic injections. After clearing out the 
 cavity, it may bt> loosely filled with strips of iodoform 
 gauze, which will prevent further hemorrhage and 
 complete the process of disinfection. The strips may be 
 allowed to remain for forty eight hours. When removed 
 the irrigation mny be renewed, and drainage kept up by 
 strips of gauze inserted into the opening in the cyst cavity, 
 and by a few pieces inserted loosely into the vagina. 
 
 Cildiotomy has given good results. The walls of the 
 cyst, if possible, are to be fixed to the abdominal parietes 
 by caieful suturing, and the margins protected with pads 
 of iodoform gauze. The cyst wall is then incised, emptied 
 of its contents, and packed with gauze. Such fixation of 
 the walls is often impossible, in which case the intestines 
 
PELVIC HEMATOMA. 369 
 
 aro to bo cnrofully tucked away, and the gonoral abdominal 
 cavity thoroughly walled off with several thiokiiessc^K of 
 iodoform gauze. When this has been carefully and 
 accurately done, an incision may be made into the sac, 
 and the contents removed by means of sponges. The cyst 
 cavity may be then packed with iodoform gauze, and the 
 occlusion pads previously inserted allowed to remain 
 in Situ until sufficient peritoneal adhesions have formed 
 around them to permanently wall off the peritoneal cavity, 
 and with it the intestines, from infection. By this means 
 also capillary drainage is established, and the broken 
 down material of the cyst cavity removed. In course of 
 time the gauze is gradually withdrawn, preserving careful 
 antisepsis, and a smaller quantity reinserted each time 
 until the cavity is completely filled up by granulation. 
 
 PELVIC HEMATOMA. 
 
 The effusion of blood into the connective tissue of the 
 pelvis has also been designated by the term thrombus of 
 the brodd liijoment. 
 
 Etiology. It may be produced by the influence of 
 pregnancy, or by rupture of a utero-ovarian varicocele. 
 The immediate attack is usually the result of overwork or 
 sexual excesses during pregnancy or the menstrual period. 
 
 Pdthology. The blood may form a circumscribed 
 tumor between the folds of the broad ligament, which not 
 being a closed cavity, but communicating with the pelvic 
 cellular tissue, permits the escape of blood, if abundant, 
 into the latter, and the effusion then is directed toward the 
 vagina and rectum. The tumor is usually of medium 
 size, varying from the size of the fist to that of a man's 
 head. The locality is decidedly lateral, and the contents 
 similar to that described v>^ben speaking of intra-peritoneal 
 hajmatocele. 
 
 Symptoms. It usually occurs in women who are 
 apparently in a healthy condition. Sharp pain in the 
 
370 MEDIO\L AND SURGICAL GYNiECOLOGY. 
 
 nbdomon marks the onset, accompanied by a tendency to 
 syncope. Symptoms of decided ansemia, and troubit r. due 
 to compression of the bladder are manifested, witli swel- 
 ling and tenderness of the abdomen. By bimanual exam- 
 ination, a tumor soft and pasty in consistence is felt in the 
 broad ligament, and not in Douglas' cul-de-sac. The 
 uterus is situated upon its internal surface and more or 
 less pushed aside, but it can be distinctly outlined on 
 every side. As for the other symptoms, they are the same 
 as those given for intra-peritoneal hematocele. 
 
 Treatment. Expectant treatment is the rule. If the 
 gravity of the symptoms calls for interference, vaginal in- 
 cision may be dangerous owing to the possibility of 
 wounding the uterine artery or the ureter. In such cases, 
 coeliotomy may be performed, with evacuation and drainage 
 as described for intra-peritoneal lu^matocele. 
 
 It may be evacuated by a combined operation of 
 coeliotomy and drainage through the vagina. After open- 
 ing the abdoiainal cavity and protecting it after the 
 mannev already described, the sac is carefully incised and 
 the contexts removed. Gruided by the lingers of one 
 hand in the vagina, an opening is made through into that 
 canal. The sac is then loosely packed with strips of iodo- 
 form gauze, the ends being brought out through the 
 /' vaginal opening, and drainage established by that route. 
 
 The edges in the upper opening in the sac are then in- 
 verted and drawn together by a continuous catgut suture 
 and protected by gauze. The management of the gauze 
 within the peritoneal cavity will be the same as already 
 described. 
 
GENITAL TUBERCULOSIS. 371 
 
 CHAPTER XXXII. 
 
 GENITAL TUBERCULOSIS. 
 
 Tuberculosis of the female genitals, although long 
 known, has only recently attracted special attention. It 
 was previously known only as a concomitant of advanced 
 phthisis, and it was not until coeliotomy demonstrated its 
 frequent occurrence, either alone or in combination with 
 tubercular peritonitis, that its clinical importance began 
 to be appreciated. It may involve any or all of tlie 
 various parts of the genital tract, though some portions 
 are more frequently affected than others, the order of 
 frequency being the tubes, uterus, ovaries, vagina, cervix, 
 and vulva. 
 
 Etiology. Tuberculosis of the genital tract may bo 
 either primarif or scconddry. Primary inoculation may 
 occur when the patient has been much in the company of 
 one suffering from tuberculosis. The clothes, a sound, or 
 the fingers of a physician may carry the germ. Cohabita- 
 tion with a person who has either genital or pulmonary 
 tuberculosis is a well authenticated cause in many 
 instances. The puerperal state has a large share in 
 primary infection, but whether infection can come through 
 the semen, the saliva, or the blood of a scratch, is a 
 disputed point. 
 
 Secondary genital tuberculosis is that which is devel- 
 oped ill the coarse of tubercular degeneration of other 
 organs, especially the lungs. In the great majority of 
 cases, genital tuberculosis is secondary and metastatic, the 
 infection taking place by way of the peritoneal cavity and 
 the lymph channels, from the abdominal viscera, or 
 through the general circulation from distant organs, or 
 by auto-inoculation from the secretions. 
 
 Vulva. Vulvar tuberculosis is the least common, and 
 is often unassociated with tuberculosis of other portions 
 of the genital tract, being due either to blood infection or 
 
372 MEDICAL AND SURGICAL GYNiECOLOGY. 
 
 to direct infoction. Tlui tubtTouIous ulciern may attain a 
 couHidorablo sizo and are usually Hhallow. Tluur marj^iiis 
 aro irregular, sharply out. slightly raised above tlie general 
 surface, and of a more or less granular appearances 
 
 Vagina. Vaginal tuberculosis is much mor(^ frequent, 
 and while it may bo primary, it is usually secondary to 
 tubrtrculosis affecting the higher portions of the genital 
 traci It occurs in the form of miliary tubercles, never 
 larger than millet seeds, and which in time undergo 
 caseation and break down, producing tuberculous ulcera- 
 tion. The ulcers thus formed are irregular in outline, 
 their margins sharply cut and perpendicular, the base 
 shallow, studded by granulations of varying size and color, 
 and covered by a layer of caseous material. These ulcers 
 by extension may jierforate the walls upon which they are 
 situated and lead to the formation of fistul{T3. It is gen- 
 erally limited to the posterior wall of the vagina, and does 
 not ordinarily extend below the upper third, circumstances 
 which are explained by the fact that infection generally 
 takes place by secretions from the tuberculous uterus or 
 tubes. 
 
 Uterus. Tuberculosis of the uterus is not a rare affec- 
 tion. It is generally associated with tuberculosis of the 
 tubes from which it has usually originated, and is fre- 
 quently secontlary to phthisis, or occurs as a part of a 
 general infection. It is nearly always limited to the 
 corpus uteri. When tuberculosis of the cervix occurs, it 
 is usually without any involvement of the body, and 
 appears eitluT in the form of miliary tubercles, or of tuber- 
 culous uka>ration, or as a combination of both forms. It 
 is at first limited to the endometrium, but later the 
 muscular coat becomes involved. The formation of the 
 miliary tubercles occurs just beneath the epithelium of the 
 endometrium, and may or may not be combined with in- 
 flammatory changes. The appearance of the tubercles, 
 and of ^he ulcerations resulting from them, does not differ 
 
(lENlTAL TUBliUCULOSIS. 
 
 373 
 
 t'HHriitinlly from that obsorvcd in tuln'rculoHis of other 
 inu(H)iis miMnbrfines. 
 
 In (rhroiiic ditt'uHo tulwrculosiH, tho iiiti'rior of tho body 
 of tlie uterus in filled with casoouK matorial which forms a 
 lay(>r ovct its inner surface. On H(Ta[)inK it off tiie sub- 
 jacent tissue is seen ja^^ed and irregular, and stuchled 
 with tubenies in all stag<?s of development, from the 
 typical grayish semi-transparent nodule, to the irregularly 
 shaped ulcer. As the disease progreasfiS, tubercles are 
 gradually formed in the muscular coat, which accordingly 
 undergoes hypertrophy, and leads to a consitlerable on- 
 
 r. I. 
 
 »•,(>. 
 
 Fig. 107. — Primary tuberculosis of the tubes ami ov.iries, posterior view. ( Kotscfiau.) 
 r.o. KiRbt ov.iry, enclosiiiK laseous m.-isses ev.ncuated by the tearinu apart of iulliesions. 
 r.t. KiKhl lube, ililateil and .i<lh'ireiu to iliuui, havini; fornieil part of llie w.ill of a 
 tuberculous abscess. Mie left ovary, tube, Lo. an<l l.t., and endonietriutn, c, .ire also 
 tuberculous. 
 
 largement of the uterus. By obliteration or clogging up 
 of the cervical canal, it may lead to the formation of a 
 pyomc^tra. 
 
 Tubes. The Fallopian tubes are far more frequently 
 affected by tuberculosis than any other portion of the 
 genital tract, and in the great majority of cases either the 
 uterus, or the ovaries, or both, are likewise affected. In 
 most cases it is secondary to tuberculosis elsewhere, 
 although in a considerable number of cases they are the 
 seat of the primary form. 
 
ii74 MEDICAL AND SUKOICAL GYNiECOLOOY. 
 
 Tubonnilosis of the tubes may oocur in two forniH. 
 Miliari/ fiihcrriilosis, in which 11 o tubes present the 
 fjfenernl charncteristics of miliary tuberculosis of other 
 mucous membranes, and chronic diffuse tuhcrcnh^iis, 
 which corresptmds to the like named process in the uterus, 
 and is the form familiar to all under the name cuscons 
 2)us ti(l)rs. 
 
 In advanced cases the tube is greatly enlarged, and if 
 the peritoneum is involved, its external surface is studded 
 with tubercles in various stages of development. It is 
 densely adherent to the surrounding structures, and in 
 some cases i^resenta an almost stony hardness. In most 
 instances the fimbriated extremity is occluded, but when 
 patulous caseous material will be found protruding from 
 it. On section the lumen is found more or le.ss dilated 
 and filled with typical yellowish caseous material, which 
 varies greatly in consistency, sometimes being fluid, some- 
 times it forms a soft mass, and occasionally is dry and 
 solid or even calcified. The normal appearance of the 
 mucosa has disappeared, and i>resents a ragged, ulcerated 
 sui face over which are strewn tubercles in all stages of 
 development. 
 
 A third form of tuberculosis of the tube has been 
 described, chronic jihroid tuhcrcnlosis. It differs from 
 the others in the excessive formation of fibrous tissue in 
 and between the tubercles. 
 
 Ovary. Tuberculosis of the ovary is comparatively 
 rare, and when seen is usually found in combination with 
 other forms. The process may be limited to the surface 
 of the ovary, or it may invade the entire organ. Macros- 
 copically it appears in the form of miliary tubercles, 
 caseous masses, or tubercular abscesses. 
 
 Symptoms. No period of life is exempt from genital 
 tuberculosis, but the period in which its occurrence is 
 most frequent is that of the greatest sexual activity. The 
 early symptoms are often not very clear, or so masked by 
 
GENITAL TUBERCULOSIS. ^75 
 
 thoHd of tlip primary affection that, the involvoincMit of tlio 
 ^onitals is not Huspocted. When it occurH in tlui vulvu 
 and vagina, it gives rise to symptoms oommon to all 
 ulcerative processes, and in these instances simple inspec- 
 tion is fre(piently all that will be reipiired, but a positive 
 diagnosis can be made only by the microscope. 
 
 Tuberculous ulceration of tli<i cervix may show itst^lf 
 by profuse hemorrhage, and in that way may be mistaken 
 for carcinoma. In cases in which the uterus is affected 
 there is usually a very profuse leucorrluBa, which in some 
 instances consists of a mixture of the caseous material 
 and the ordinary secretions. The uterus will be found 
 enlarged, and there will bo associated with it menstrual 
 disturbances. 
 
 The symptoms produced in tuberculous disease of the 
 ovaries and tubes <,re in most instances overlooked in the 
 generul condition, and even no symptoms at all may be 
 present. When the process is limited to the tubes and 
 ovaries, the symptoms will vary from those of a simple 
 salpingitis to those of the most severe form of pelvic 
 abscess, and in spite of careful examination nothing will 
 be found to indicate the tuberculous nature of the affec- 
 tion. Amenorrhoea is not necessarily an accompaniment, 
 but if it occurs it is usually due to the coexisting phthisis. 
 
 Diagnosis. From the clinical history afforded, it be- 
 comes evident that prior to the discovery of the tubercle 
 bacillus a positive diagnosis of genital tuberculosis could 
 not be made. 
 
 Tuberculosis of the vulva and vagina may be con- 
 founded with (jr(tni(l(ir inujiniUs. When the frequency 
 of the latter is compared with the rarity of the former, it 
 is in itself almost sufficient for a diagnosis; but when one 
 considers that when tuberculosis of the vagina occurs it 
 is in phthisical women, and that granular vaginitis is 
 frequently associated with pregnancy or gonorrluea, a 
 mistake should not occur. Tuberculosis should also be 
 
.37(5 MUDKiAL AND SUIUlKiAL (lYNiECOUKJY. 
 
 (liii^iioHod from Uw pdpiihir and ulcrntfin' si/plu'lidrs, 
 which may bt< doiio by thti hiHtorv by th(i rutins abHuace 
 of pain, and by thci total disappi^aianco of tho lattor uiidiir 
 antiKyi)hiliti-.; trcvitiiKMit. 
 
 JlcrfX'fic cniitlions about thc^ vulva oocnir as Hinall 
 cysts tilled with cKwir fluid, aiid usually appcmr about tho 
 monstrual period, and disappear soon after. Ihinl and 
 .so/7 cliancrcs may be diagnosed by tho history, by tlu^ 
 appearance of the patient, and by their well known 
 characteristics. 
 
 Tuberculous ulceration of the cervix nay be diat^nosed 
 from ('(irrinonid by the aid of the microscope. In tuber- 
 culosis of the uterus, and in all cases where there is the 
 slightest suspicion of genital tuberculosis, the vaginal and 
 uterine secretions should be inspected with the greatest 
 care for tubercle bacilli. Tho diagnosis of tuberculous 
 disease of the tubes and ovaries is more difficult than that 
 of tuberculous disease of the uterus, for the reason that 
 their secretion is not so readily obtained for examination, 
 and it is doubtful if, when the disease is limited to these 
 organs, a i^sitive diagnosis can bo made. 
 
 Diagnosis. Primary tuborciilosis of the genitals is 
 always to be regarded as a serious affection, as it always 
 presents the possibility, as do other foci of tuberculosis, of 
 a general infection, with its uniformly fatal termination. 
 Tuberculosis of the tubes and ovaries tends to the produc- 
 tion of tubercular peritonitis, or it may go on to the for- 
 mation of an abscess in them. The results of operative 
 treatment have been quite satisfactory. If the tuberculosis 
 is limited to the tubes and ovaries, the prognosis after 
 removal will hardly be more grave than if they wore re- 
 moved for tho usual inflammatory affections. 
 
 Treatment. Remembering the sources of primary in- 
 fection, the necessity for prophylaxis becomes apparent. 
 Possible infection by physician or attendant should be 
 carefully guarded against. Persons afflicted with genital 
 
TUBERCULOSIS OF THE PElilTONEUM. 377 
 
 tuborculofliH, wliotlior mnlo or ft^innlo, should \hi improHHod 
 with thl^ dnngorH of infection by coitus. The trtiiitiiKitit 
 will vary nccordiiig ns different portions of the genital 
 tract are affected, and whether the affection is primary or 
 secondary. 
 
 Ulcers of the vagina and vulva may be made to dis- 
 appear by the application to tliem of tincture of iodine, 
 iodoform, or la(;tic acid. If a tuberculous ulcer of the 
 cervix is recognised, and fails to respond to conservative 
 treatment, it should at once be amputated. If the process 
 is limited to the uterus, it should be curetted and iodoform 
 suppositories inserted. If there is the slightest recurrence 
 of the infection, the uterus should be removed by vaginal 
 hysterectomy, and in such cases it is best to remove tlio 
 tubt>s and ovaries as well. 
 
 The question as to the removal of the tubes and ovaries 
 when they are the sent of tuberculosis, is a difficult one. 
 As primary tuberculosis is rarely diagnosed, the propriety 
 of their removal is seldom faced, but when discovered in 
 cases of coeliotomy undertaken for other causes, there 
 should be no hesitation as to the propriety of their 
 removal. In advanced or decided cases of pulmonary 
 phthisis, there should be no thought of operating. In 
 cases associated with tuberculous peritonitis, there need 
 be no hesitation to perform ca3liotomy and remove the 
 tubes and ovaries, and uterus as well, unless the general 
 condition of the patient is altogether unfavorable. 
 
 CHAPTER XXXIII. 
 
 TUBERCULOSIS OF THE PERITONEUM. 
 
 In connection with miliary and chronic pulmonary 
 tuberculosis, it is not uncommon to find the peritoneum 
 studded with small gray granulations, and they ai'e 
 constantly present too on the serous surfaces of tuber- 
 
378 MEDICAL AND SURGICAL GYNiECOLOGY. 
 
 culous ulcers of the intestines. Apart from these con- 
 ditions the membrane is often the seat of extensive 
 tuberculous disease, which occurs in the following forms: — 
 
 Acute miliarij tuberculosis, with sero-fibrinous or 
 bloody exudation. 
 
 Chronic tuberculosis, cliaracterized by larger growths, 
 which tend to caseate and ulcerate, leading to perforation. 
 The exudate is jjurulent or sero-purulent, and is often 
 sacculated. 
 
 Clironic fibroid tuberculosis, which may be subacu'e 
 from the onset, or which may represent the final stage of 
 the acute form. The tubercles are hard and pigmented, 
 there is little or no exudation, and the serous surfaces are 
 matted together Vy adhesion. 
 
 Tubercular peritonitis occurs at all ages, and is 
 common in children associated with intestinal and mesen- 
 teric disease. The incidence is most frequent between 
 the ages of twenty and forty. 
 
 Symptoms. The process may be latent and not cause a 
 single symptom, the condition being accidentally met with 
 during ccBliotomy for some other lesion. Sometimes the 
 onset is so sudden and violent that a diagnosis of enteritis 
 or hernia is made. Many cases set in acutely with fever, 
 abdominal tenderness, and the symptoms of ordinary 
 acute peritonitis. Cases with slow onset, abdominal 
 tenderness, tympanites, and low continuous fever, resemble 
 typhoid fever very closely. Ascites is frequent, but the 
 eft'usion is rarely large, and is sometimes hemorrhagic. 
 Tympanites is generally present, particularly in the more 
 acute cases. Fever is also a marked symptom in acute 
 cases, and the temperature may reach 104° F. In many 
 cases it is slight, and in the more chronic cases subnormal 
 temperatures are common. Associated with this, there is 
 usually abdominal pain, imperfect digestion, loss of flesh, 
 emaciation, sometimes diarrhoea, and occasion.olly pigmen- 
 tation of the skin, resembling at times that of Addison's 
 
TUBERCULOSIS OF THE PERITONEUM. 379 
 
 disease. A striking peculiarity of tuberculous peritonitis 
 is the frequency with which the condition simulates, or is 
 associated with tumor, and is to be remembered when 
 making a diagnosis of abdominal and pelvic tumors. 
 
 Orncntdl tumors may form from the puckering and 
 rolling up of this membrane until it forms an elongated 
 firm mass, attached to the tranverse colon and lying across 
 the upper part of the abdomen. 
 
 Sdcculdtrd cxmUi.fion may occur, in which the effusion 
 is limited and confined by adhesions between the coils of 
 intestines, the parietal peritoneum, the mesentery, and the 
 abdominal or pelvic organs. This encysted exudate is 
 most common in the middle zone, and has frequently been 
 mistaken for an ovarian tumor. It mfiy occupy the entire 
 anterior portion of the peritoneum, or there may be a 
 more limited saccular exudate on one side or the other. 
 It may be completely within the pelvis proper, associated 
 with tuberculous disease of the Fallopian tubes. In 
 rarer cases the tumor may be due co the great retraction 
 or thickening of the intestinal coils. Not only the small 
 intestine, but the entire bowel, from the duodenum to the 
 rectum, has been found forming such a hard nodular tumor. 
 
 Mesenteric glcmds occasionally form very large tumor 
 like masses, but they are more commonly found in 
 children than in adults. 
 
 Diagnosis. The prodromata, the gradual onset, the 
 progressive development, suggest the tuberculous nature 
 of the disease. The presence of extensive induration 
 about the Fallopian tubes, not traceable to labor, abortion 
 or gonorrhoea, and of tuberculous disease elsewhere in the 
 system, aid materially in differentiating it from peritonitis 
 due to ordinary salpingitis or appendicitis. 
 
 Mali</nant peritonitis is seldom encapsuled, and is 
 more often connected with a tumor or characteristic 
 enlargement of an organ, has less extensive acute attacks, 
 and runs a more rapid course. When tuberculous peri- 
 
380 MEDICAL AND SURGICAL GYNECOLOGY. 
 
 tonitis progresses more rapidly, the charncteiistic symp- 
 toms of it will prevent it being confounded with malignant 
 disease. 
 
 Encysted tuberculous peritonitis may, as has been 
 said, be mistaken for an ovarian in mar. In addition to 
 the local signs of ovarian tumor already mentioned, the 
 presence of salpingitis, the induration of the sacro-uterine 
 folds as felt by the finger introduced into the rectum, the 
 slow development and other signs and symptoms of tuber- 
 culosis, will serve to distinguish it. An ovarian tumor 
 with pelvic adhesions presents severe increasing pelvic 
 symptoms, with proportionately less general depression, 
 loss of health and emaciation than tuberculosis. 
 
 Treatment. The treatment in general consists in that 
 which belongs to tuberculosis elsewhere. Attacks of 
 peritonitic pain should also be treated on the general 
 principles laid down for peritonitis occurring under other 
 circumstances. Bismuth and salol, the digestive ferments, 
 and a carefully regulated diet may be required for gastro- 
 intestinal irritability and impaired digestion. Constipa- 
 tion or diarrhoea should be combated by appropriate 
 treatment. Counter-irritation over the abdomen by tinc- 
 ture of iodine, and later by gentle pelvic massage, may be 
 employed. Encysted peritonitis shouhl be relieved by 
 lappi/ig, or by a short abdominal incision and the in- 
 Kufiiation into the sac of a small quantity of iodoform. 
 Drainage is seldom necessary, unless adhesions have been 
 separated that leave oozing surfaces. 
 
PART FOUR. 
 DISEASES OF THE FEMALE BREAST. 
 
 CHAPTER XXXIV 
 
 ANATOMY. THE NIPPLES. NEUROSES. MASTITIS. 
 MAMMARY ABSCESS. CYSTS. 
 
 For a proper consideration of the various affections 
 of the mammary gland, it is essential that there should be 
 a knowledge of its anatomical position, its structure, and 
 its physiological functions. Into these it is impossible to 
 go here, but a few points regarding its blood vessels and 
 lymphatic channels will not be out of place. 
 
 The breast receives nearly its entire arterial supply 
 from the thoracic branches of the axillary, namely: — The 
 acromio-thoracic, the long thoracic, and the external 
 mammary arteries, all entering the gland from *^^he upper 
 and outer aspect. Branches are sent to the sternal side of 
 the gland by the perforating and intercostal branches of 
 the internal mammary artery. The venous blood returns 
 througli the veins accompanying the arterial vessels. 
 
 The lymphatics of the breast consist of two sets, an 
 axillary and a mediastinal. These are further subdivided 
 into superficial and deep sets. The main lymphatic 
 channels pass either superficially, or deeply, from the 
 upper and outer portion of the gland, the former over, the 
 latter in the fascia which covers the pectoralis major 
 muscle. The majority of these lymphatics bend around 
 the pectoral muscle and ontt^r the glands there; others pass 
 directly to the glands about the axillary artery. Still 
 others, belonging to the superficial set, pass upward and 
 outward, joining first with the lymphatics of the arm 
 before entering the glands about the axillary vessels. The 
 
382 MEDICAL AND SURGICAL GYNiECOLOGy. 
 
 mediastinal set of lymphatics, consisting of a superficial 
 and deep set, drain the sternal side oi: the gland, particu- 
 larly the upper and inner quadrant. T!iey pass into the 
 glands of the anterior mediastinum by perforating the 
 intercostal spaces, those on the right side joining usuully 
 with the lymphatics from the convex surface of the liver. 
 A knowledge of the lymphatic distribution is important, 
 particularly in carcinoma, as it explains the common 
 infection of the axilla, and the rarer infection of the 
 mediastinum and liver which may occur in this disease. 
 
 Malformations or deformities of the breast are very 
 rare and of no practical importance. 
 
 Diseases of the nipple. Apart from inflammatory 
 disturbances, the nipple is rarely affected by disease. 
 
 Inflammation may be excited by any irritation, but it 
 is seldom found except during lactation, either early in 
 its course, or when lactation is unduly prolonged. The 
 alternate wetting and drying associated with nursing the 
 child, is the exciting factor. In the mi.der cases the 
 nipple and surrounding areola are ; fected only. In 
 severe and neglected cases the process -ay involve the 
 neighboring skin and underlying fascia, or even the gland 
 itself. This extension is due to the Assuring which opens 
 up the lymph tracts to the entrance of pyogenic micro- 
 cocci. These micrococci, which are commonly present in 
 the skin and mouth secretions, enter and excite lymphan- 
 gitis, and by spreading deeply may set up mastitis, 
 either of which may terminate in mammary abscess. In 
 the milder cases the nipple and areola become red and 
 swollen, then fissured, leaving small ulcers, constituting 
 what is commonly termed cracked nipples. Pain is 
 always present, usually smarting in character, and inten- 
 sified during the nursing of the infant. In severe cases 
 the ulceration may extend deeply, leading to considerable 
 destruction of the nipple substance. .. 
 
DISEASES OF THE BREAST— NEUROSES. i^83 
 
 Tr'catment. In the milder cases thorough cleanliness 
 is all that is usually required. Washing the breasts with 
 warm boracic acid lotions, and thorough drying after 
 nursing, v/ill accomplish this. When fissures appear, a 
 breast shield should be worn when the child is nursing, 
 and in the intervals an astringent lotion, such as the 
 glycerolo of tannic acid, used. In severe cases the use of 
 the breast will have to be abandoned, the ulcers touched 
 with a caustic, such as the solid stick of silver nitrate, oud 
 the breast compressed with a firm bandage after the appli- 
 cation of a belladonna ointment or lotion, or bettor still, 
 perhaps, the oleato of atropine in two-per-cent strength. 
 
 Neuroses of the breast are not unfrequently found in 
 young unmarried women. As a rule the condition is most 
 marked at, or about the menstrual periods. This affection 
 is qi 'te a common manifestation in hysterical women. 
 The features usually noted are a peculiar sensitiveness in 
 the gland, at times amounting to pain, neuralgic in 
 character, and usur^ly localized, but may shoot to the arm 
 or shoulder. On examination no departure from the 
 normal can be detectv3d. It is important to examine the 
 breasts carefully for tumor nodiles and to exclude these 
 as causal agents. 
 
 The treatment of these neurotic conditions must be 
 directed to the general health of the patient, no attention 
 being paid to the breasts; in fact attention should be 
 directed entirely away from them, as local treatment 
 usually intensifies the trouble. 
 
 Inflammation of the breast. (Mammitis, mastitis, 
 mammary abscess.) Inflammatory conditions of the 
 breast may be either acute or chronic, but the vast 
 majority of such must be placed in the former category. 
 
 Acute mastitis may follow traumatism, but most 
 commonly it is found during the first weeks of lactation, 
 or late in its course, being due to the extension of infective 
 material from cracked nipples. It may also be found in 
 
384 MEDICAL AND SURGICAL GYNJICOLOOY. 
 
 infaris shortly after birth, duo to attempts of the nurse 
 or mother to break the "nipple strings;" ov at puberty, 
 owing usually to some trauma or irritation of the then 
 sensitive breasts. All cases of acute mastiffs, not directly 
 traumatic, are due to the entry of infective bacteria, par- 
 ticularly the pyogenic micrococci, of which staphylococci, 
 pyogenes aureus and albus, play the chief part. Cold, 
 inefficient emptying of the breasts, irritation from the 
 clothing or other slight trauma, and prolonged lactation are 
 factors predisposing to infection. Infection, though com- 
 monly of local origin through the milk ducts or lymph 
 channels, may at times take place by way of the blood 
 current. 
 
 The symptoms are at first a sense of fulness and 
 discomfort, followed by swelling of the breasts and ten- 
 derness, often localized at first to a single lobule or group 
 of lobules. Pain is present, sharp and lancinating, and 
 often shooting to the axilla. The skin next becomes tense, 
 red, and indurated. Constitutional disturbances are 
 manifested by slight chill with subsequent fever. The 
 inflammation may terminate in resolution, or it may pass 
 on to suppuration and the formation of an abscess. 
 
 Mammary abscess. When the inflammation termi- 
 nates in pus formation, the parts, usually localized to a 
 group of lobules, become tense, boggy, and fluctuation 
 appears. In true mastitis pus forms in the gland, but pus 
 may form either over or under the gland. Superficial 
 abscess formation may mean no involvement of the gland 
 tissue, but frequently it is but a forerunner, or rather a 
 concomitant of abscess formation in the gland itself, 
 Pus formation beneath the gland is commonly due to the 
 direct passage of infective pyogenic bacteria to the lymph 
 tracts in that situation, the gland itself being only occa- 
 sionally involved. In such cases the inflammatory process 
 is behind the gland, and when pus forms the gland is 
 pushed forward and floats, as it were, upon it. Pointing 
 
DISEASES OF THE BREAST- -MASTITIS. 385 
 
 of the abscess usually takes place at the lower margin of 
 the breast. 
 
 Trcdttnciit. The treatment of mastitis at p'jrioda other 
 than lactation, consists in keeping the gland at perfect 
 rest. This is best secured by bandaging with firm com- 
 pression the affected breast, and at the same time fixing 
 the arm to the chest. The bowels should be opened by a 
 sharp saline purgative, and kept acting freely. Tonics 
 should also be given. Locally, soothing astringent lotions, 
 as lead and opium wash, should be applied to the breast. 
 If the inflammation tends to pass on to pus formation, 
 these lotions should be replaced by hot fomentations, or 
 by aseptic poultices, such as linseed meal boiled in carbolic 
 water (1 to 80) . When pus forms it must be freely opened. 
 
 Mastitis during lactation always shows a great tendency 
 to proceed to abscess formation. During lactation, if 
 mastitis develops, the child should be withdrawn from the 
 breast, and distension relieved either by gentle stroking, 
 or by the proper use of the breast pump. The breasts 
 must also be placed at perfect rest by firm bandaging, and 
 other points attended to according to the manner already 
 described. If pus forms it must be evacuated at once. 
 
 In opening an abscess in the breast the incision should 
 always be made in a line radiating from the nipple, thus 
 avoiding the milk ducts. The opening should be freely 
 made, the abscess cavity irrigated and packed with a 
 little iodoform gauze, and the skin incision partly 
 approximated. When the abscess is behind the gland, 
 the incision should be made where the abscess tends to 
 point, that is at the lower border of the gland. After 
 evacuation of the pus the cavity should be thoroughly 
 irrigated and drained as before. A rubber drainage tube 
 may be sufficient for such cases, as the dependent position 
 affords in itself good drainage. 
 
 Chronic mastitis. (Interstitial mastitis.) Chronic in- 
 duration of the breast is a proliferative inflammation of 
 
386 MEUICAL AND SUUQIOAL GYN/ECOLOGY. 
 
 some of its lobulos. It may be due to various onuses, nutl 
 there are differont varieties. It may bo found arisinji^ Jato 
 during lactation, or more commonly in married women 
 after the menopause. In both these conditions it may 
 be mistaken for carcinoma, and 't is well to remember 
 that 8' me ^f such cases do terminaio in carcinomitous for- 
 mation. Besides those commoner conditions, we may have 
 a chronic mastitis set up by continued irritation of the 
 clothing. Tuhercnlosis and syphilis at times attack the 
 breast, usually taking the clinical form of chronic mastitis. 
 Either of these conditions may lead to the formation of 
 chronic or cold abscess of the breast. Abscess formation 
 is at times found in connection with chronic mastitis 
 occurring late in lactation. 
 
 In chronic mastitis there is an extensive proliferation 
 of the connective tissue cells, and to a slighter extent of 
 the epithelium of the gland alveoli, with a slight leucocytic 
 infiltration. The connective tissue cells develop into 
 adult fibrous tissue, and by their contraction load to in- 
 duration, and to occasional adhesion of the skin and 
 retraction of the nipple. The gland acini are also pressed 
 upon and gradually destroyed. In some parts small re- 
 tention cysts may be formed by the obliteration of the 
 ducts. 
 
 The disease is first noticed as a circumscribed indura- 
 tion in the breast, moving only with the breast tissue, and 
 affecting but one or two lobules at first. The affected 
 area is tender on pressure. Pain, if present, follows the 
 distribution of the intercostal nerves. The indurated area 
 is commonly wedge-shaped, with apex toward the nipple, 
 and gradually increases in size. The induration has not 
 the stony hardness of scirrhus, nor does it become adherent 
 to underlying structures. The axillary glands are at times 
 somewhat enlarged, but never indurated. The skin over 
 the area of induration may become somewhat dimpled, 
 and the nipple retracted, owing to the contraction of the 
 
DIUEASES OF THF BRii.\ST — CYSTS. 387 
 
 nowr rormod fibrous tissue, ^n n cnso wlicro tho din^nosis 
 botwoen this affection and scirrhus is doubtful, thoro 
 should bo no hesitation in making an exploratory incision, 
 for in this, as in the case of scirrhus, early operation is 
 the only hope for eradication of the disease. 
 
 Trcdtment. Tonics and good food are indicated in 
 most cases of chronic mastitis. Potassium iodide may 
 also be administered, and is essential in syphilitic cases. 
 Locally, various preparations may be made use of, such as 
 a two-per-cent oloate of mercury or iodide of potassium 
 ointment, or belladonna plaster. When used they should be 
 applied with firm pressure, and the treatment continued 
 for some weeks. If pus forms it must of course be im- 
 mediately evacuated and the cavity irrigated and drained. 
 In cases persisting for months, and in tubercular mastitis, 
 amputation of the breast is called for, as long continued 
 cases, if left alone, are apt to become malignant. 
 
 Simple cysts. Cysts may occur in nearly all forms of 
 tumor of the breast, the common cysts being found in 
 connection with adenomata of the breasts, but the cysts to 
 be now considered are those apart from such tumor forma- 
 tion. Of the simple cysts there are two classes: — 
 
 1. Serous cysts, due to distension of lymph spaces in 
 the connective tissue stroma. They contain a torous fluid 
 and seldom reach a large size. 
 
 2. Retention cysts, of which there are several varieties. 
 (a) The large duct cysts. (/>) Small duct cysts or gland- 
 ular cj'sts. (c) Involution cysts. 
 
 The duct cyst is due to blocking of one of the larger 
 milk ducts, leading to distension of the duct. Occurring 
 during lactation, such blocking leads to milk cysts or 
 galatocele. The smaller duct cysts are usually multiple, 
 and are due to dilatation of smaller ducts and gland 
 alveoli, from blocking of the lobular ducts. These cysts 
 contain a yellow, or a brownish yellow mucoid fluid. The 
 third class, or involution cysts, are of very small size, and 
 
388 
 
 MEDICAL AND SURGICAL QYN-ECOLOGY. 
 
 occur in oldorly pooplo, or as a result of chronic inaHtitis. 
 Thoy nro of no importnnco. Homorrhago may occur into 
 any of those varieties, forming a nemorrhagic cyst. 
 
 Serous cysts and duct cysts give rise to the same 
 symptoms, and are found most often between the ages of 
 thirty and forty years. They appear as rounded or ovoid 
 swellings, situated usually in the centre of the gland, have 
 an elastic feel, are freely movable, and do not lead to skin 
 adhesion. Galatocele or milk retention cysts occur during 
 lactation, and are filled with a milky fluid changed by 
 absorption and inspissation. 
 
 The treatment consists in laying open the cysts and 
 removing the contents. In serous cysts the cavity may be 
 allowed to granidate up from the bottom. In other forms 
 it will usually be necessary to dissect out the cyst wall, or 
 to remove the effected zone entire. In such cases the 
 wound may be sutured and treated as an ordinary incision. 
 
 CHAPTER XXXV. 
 
 DISEASES OF THE FEMALE BREAST CONTINUED. 
 
 NEOPLASMS. 
 Tumors of the breast constitute the largest class of 
 affections of this organ. Various classifications are given 
 in the larger text books, but the following is here put 
 forward as resting upor a fairly accurate pathological and 
 clinical basis. Tumors of the breasts may be: — 1. Simple 
 OT innocent ; 2. Mdlignant. I'his classification must be 
 further subdivided as follows: — 
 
 1. Benign, innocent, or histioid tumors made up of: — 
 a. Tissues resembl/ng the fully developed 
 connective tisswes, as fibroma, lipoma, 
 -o I chondroma, etc. 
 
 />. Tissues resemblinj;^ the more specialized 
 connective tissuen, as angioma, neuroma, 
 etc. 
 
DISEASES OP THE BREAST - -NEOPLASMS. 
 
 389 
 
 Common 
 Hiiuplo 
 tumor. 
 
 Usunl 
 
 sarcomatous 
 
 tumor. 
 
 V. Tissues coriHistiug of opitholial olcmc^nts 
 nirnnged fairly typically in alvooli, with 
 distinct lumon, and a stroma of fully 
 developed connective tissue, as adtuioma 
 and its subvarieties, adeno-fibronm, cyst- 
 ndonomn, and papillary cysts. 
 
 2. Mdlifjiuirit tumors made up of : — 
 
 Ui. Tissues of the nature of class, e, in simple 
 tumors, in which the stroma is not fully 
 developed, but embryonic, that is con- 
 sisting of young forms of connective 
 tissue, adeno-sarcoma and its sub-class 
 sero-cystic .sarcoma. The distinction 
 between class, r, and this one is often 
 more pathological than clinical. 
 
 b. Tissues made up entirely of embryonic, 
 that is to say, young forms of connective 
 tissue. Sarcoma (pure). 
 
 ('. Tissues made up of glandular epithelium 
 arranged atypically in alveoli, by a con- 
 nective tissue stroma, and without base- 
 ment membrane. Carcinoma. 
 
 Of all cases of tumor of the breasts, including cystic 
 tumors, over eighty per cent are carcinomatous, and about 
 three per cent sarcomatous, either pure sarcomata or 
 adeno-sarcomata. Thus malignant tumors constitute 
 about eighty five per cent of all breast tumors. ( )f the 
 remainder, . adenomata or their subvarieties constitute 
 nearly the entire percentage. 
 
 The simple tumors, fibroma, lipoma, angioma, and 
 adenoma are rare, with the exception of the last named, 
 end as they do not differ from similar tumors situated 
 in other regions, it will not be necessary to refer to them 
 further here. 
 
 Adenomata. These tumors are made up of epithelial 
 cell elements, spheroidal or cubical in shape, arranged 
 in olveoli with a distinct lumen and a limiting base- 
 ment membrane, by a fibrous connective tissue stroma. 
 
390 
 
 MEDICAL AND SUROICAL GYNiECOLoaY. 
 
 Puro ndiMiomnta closoly rof«niblo tho true glniul Hhhuo 
 itwlf, (liffiiring howovor in tho niraloHS nrnmgomoiit of ti 
 nlvooli, niul thd nbsenco of tho propor ducts. In the pure 
 form ndciiomatn nn^ rnns commonly wo find in Huch 
 growtiiH a coiiHidiiniblo nmount of fibrous stroma, (jonsti- 
 tuting Jihro-ddciKnud, tho couimon simple tumor of the 
 bronst. Other modifications in structure of the adenoma 
 are found constituting further subvarioties. Some of tho 
 glandular alveoli may dilate, and their lumen become 
 filled with a serous, mucous, or more rarely, a milk-like 
 fluid, at times somewhat dark in color. These dilated 
 alveoli may themselves etdargi^ greatly, or more commonly 
 neighboring dilated alveoli run together forming smaller 
 or larger cysts, and constituting tho cijstic (tdcnomata of 
 the breast. Into these cystic spaces prolif^^rous ingrowths 
 of the cystic wall.-}, consisting of tho frame work of connec- 
 tive tissue covered with the epithelial lining of the cyst 
 wall, may occur. These ingrowths constitute tho pvo- 
 lifcroHs nuimmdrj) cysts, or piipilldvy cystonuifd of the 
 breast, and are analogous to the papillary cysts of tho 
 ovary. Cystic adenomata constitute about eighty five per 
 cent of the various cystic formations in the breast. In 
 some adenomatous formations the stroma, instead of btdng 
 of a type of fully developed connective tissue, contains more 
 or loss embryonic or young connective tissue. These are 
 the adeno-sarcomdUi of the breast. At times the epithe- 
 lial lining of the alveoli of the tumor takes on an 
 atypical course, breaking through the basement membrane, 
 forming atypical alveoli. This is a cdrcinomaious change 
 and though it occurs but rarely, its possibility should 
 always be borno in mind. 
 
 Adenomd and jibro-ddenoma may bo considered to- 
 gether. These tumors are found nearly always between 
 the ago of puberty and thirty five years, being most com- 
 mon between seventeen and twenty seven. They occur as 
 a rule in otherwise healthy women. The tumor appears as 
 
DISEASES OP THE BREAST— NEOPLASMS. 
 
 391 
 
 jiHlowly growing iukIuIcs commonly in the uppc'r linlf of tlio 
 ^land; it in frot^ly movablo, (unuimsrribod. and roundt^l, 
 and at times lobulatwl. The noduU'H foci firm, and 
 may vary in si/.o from a poa upwardH; commonly tl'.cy 
 reach tlic sizo of a wjvlnut, but con.sidi^rably lHr^l^r growths 
 may be found. The nkin \h rarely involv(>d, and if ho, 
 only by direct presHure. The growth may become^ more 
 rapid during pregnancy _ 
 
 or lactation. Pain in the iflss^xvK v,v 
 
 nodule i* seldon. '^om- '^^M^^f^f^J^Uv'^ 
 
 ;"SF--*a8 
 
 
 
 Vui. io8. — Fibro-atlenonia of the breast. The 
 glandular tissue is l).-\<lly developed, and is 
 mingled with nnich filirous tissue. 
 
 plained of, but tii«ro may 
 be uneasinesH oi slight 
 tendernesB in neurotic 
 patients. Shooting pains 
 through the breast are 
 not an infrequent symp- 
 tom, but the axillary 
 glands are not involved. 
 
 Cijstic (idenomd usually 
 occurs at a somewhat later 
 
 period than tibro-adenoma, being most common between 
 thirty and thirty five years, though not wholly confined 
 to that period. The tumor grows larger than the simple 
 adenoma, which they resemble clinically, at times reaching 
 one or two pounds. Their later appearance, larger size, 
 their frequent irregularity of surface, and the demonstra- 
 tion of points of fluctuation, are diagnostic features. 
 Many of the cysts are so tense that fluctuation may be 
 most difficult to make out. 
 
 The papilldry cysts present the same general features 
 as the cystic tumors. Often the cysts are so filled with 
 ingrowths that clinically these tumors are solid, and they 
 may even appear, on superficial examination when re- 
 moved, to be solid fibro-adenomata. 
 
 Cystic adenomata do not invade the breast tissue, but 
 pressure may lend to atrophy. The skin may be involved 
 
392 
 
 MEDICAL AND SURGICAl GYNiECOLOGY. 
 
 by pressure of a largo tumor, but it is never infiltrated. 
 The glands are not involved except there bo some accom- 
 panying inflammation, when they may be slightly enlarged 
 and tender. 
 
 The treatment of all varieties of adenomatous tumors is 
 excision. Whon they involve but a small portion of the 
 gland structure, as in most cases of simple adenoma and 
 
 Fig. 109. — Proliferous cyM adenoma— «, termination of an acinus; h and c, the tissus lie 
 tween the .-icini taking on incrc.->sed Rrowth and pushing into and dilating the acini into 
 cysts. (Billroth.) 
 
 early cystic trouble, the growth cpn be excised without 
 injuring the secxetive function of the breast. The skin 
 incision in such cases should radiate from the nipple, 
 avoiding the ducts, and should cut to the capsule, when 
 the growth may bo either enucleated or dissected away 
 with its capsule. Enucleation is advisable in simple cases, 
 while if cystic change occurs, the latter procedure should 
 be employed. When the tumor is large, or involves the 
 gland tissue extensively, the breast must be amputated. 
 
DISEASES OF THE BREAST — NEOPLASMS. 393 
 
 Recurrence after complete removal does not take place. 
 Further nodules may occasionally appear, but these will 
 have developed from now foci. 
 
 Sarcoma and adeno-sarcoma. About three per cent 
 of the tumors of the breast are sarcomata, and the majority 
 of them belong to the mixed variety, adeno-sarcoma, the 
 remainder being derived from the connective tissue with- 
 out change in the epithelial elements. Sarcomata begin 
 most commonly between the ages of thirty and forty, and 
 attack chiefly the central area of the gland. Ac first 
 they appear as small, slightly lobulated, freely movable 
 growths, and early it is impossible to differentiate them 
 from adeno-fibromata. The growth, however, is much more 
 rapid, advancing as much in weeks as the simple tumor 
 does in months. The growth soon becomes large, less 
 movable, and often somewhat adherent to the surrounding 
 parts. It is also more elastic, softer, and of more unequni 
 consistence than a simple tumor. In an adeno-sarcoma 
 the glandular part may undergo the same changes as occur 
 in simple tumors, and cysts roa;y thus be formed. Cystic 
 sarcomata rapidly enlarge, and hemorrhage very frequently 
 takes place into the cysts. As a rule, sarcomata of the 
 breast are, until late in their course, distinctly encapsuled. 
 Later they infiltrate the gland structure and involve the 
 skin, which becomes first blueish, and its veins dilated. 
 Later the skin becomes dusky red, and ulcerates, owing 
 both to pressure and infiltration, After ulceration the 
 tumor may protrude as a bleeding fungoid mass. The 
 axillary glands are seldom involved, as dissemination 
 occurs by way of the blood current. SeccJary growths 
 are most common in the lungs, and when they occur, are 
 always of the nature of pure sarcomata, even though the 
 primary growth be an adeno-sarooma. 
 
 Treatment. In the early stages the treatment does not 
 differ from that of adeno-fibroma. Later amputation of 
 the breast with free and wide extirpation of the surround- 
 
31)4 
 
 MEDICAL AND SURGICAL GYNAECOLOGY. 
 
 ing skin, is essential. With early excision recurren(!e is 
 uncommon, but when the tumor is large, recurrence not 
 infrequently may occur locally, or there may be a genciral 
 dissemination of the growth. Local recurrences shouhl bo 
 freely removed. The prognosis after free excision is fairly 
 good, as about two thirds of the cases show no return. If 
 left alone the tumor has always a fatal issue, due to ex- 
 haustion from ulcerative discharges, or from continued 
 hemorrhage, or to general dissemination, or to the 
 cachexia which appears late in the disease. 
 
 Carcinoma. Carcinomata, or cancers, comprise the 
 vast majority of new growths in the breast, making up 
 over eighty per cent of the tumor formations in this 
 situation. As compared with neoplasms elsewhere, it also 
 forms a large percentage, comprising seventeen per cent 
 in the extensive series collected by Roger Williams. In 
 tlie female, the breast and uterus aie the usual seats of 
 carcinomatous formations. 
 
 Carcinoma may attack the breast in all its varieties, 
 but spheroidal-celled carcinoma is by far the most common, 
 comprising from ninety seven to ninety nine per cent of 
 such formations. All forms of spheroidal-celled carcinoma 
 may be found — sci'rrhiis, enccphaloid, and culloiti— hut 
 scirrlius is the most common form. S<)U(inioi(s-e('ll('(l car- 
 cinoma or epithelioma may attack the skin surface subse- 
 quent to a continued intractable eczema — the so termed 
 Paget's disease. This is very rare, at least in this section. 
 Colmmiar-celled carcinoma, originates from the ducts of 
 the breast, comprising the villous or duct cancer. 
 
 The spheroidal-celled carcinoma originates from the 
 gland structure itself, and its varieties, scirrhus, encepha- 
 loid, and colloid, are differences only in the amount and 
 character of the epithelium as compared with the stroma. 
 The larger the number of epithelial cells, compared with 
 the stroma, the softer will be the growth, and the more 
 malignant its character; the more embryonic in character 
 
DISEASES OF THE BREAST —NEOPLASMS. 
 
 395 
 
 the epithelial cells, the more rapidly will they tend to 
 disHoniinate. Colloid cancer consists of a colloid degen- 
 eration of the epithelium of scirrhus or encephaloid, 
 a degeneration which lessens their malignancy very 
 materially. 
 
 In the causation of cancer of the breast there are the 
 same factors which appear to predispose to it elsewhere. 
 A family history of the disease is occasionally obtained. 
 
 [ / 
 
 
 I If,, no.— Section of a breast with scirrhus carcinoma. The growth infiltrates the fat, and 
 has caused retraction of the nipple. 
 
 Cases have been frequently recorded as fol]v)wing some 
 traumatism. Long continued irritation, particularly when 
 accompanied by proliferative (chronic) inflammation, as 
 in chronic mastitis, is the most important predisposing 
 causal factor. In the breast, as elsewhere, the actual 
 causal agent of this distressing affection has not been 
 found. 
 
 Carcinoma is most frequently found towards the 
 periphery of the gland, particularly in the upper and 
 outer quadrant of the organ. No part is however free 
 from attack. It is most common in women over forty, and 
 more especially about the menopause. The vast majority 
 of cases are found between thirty six and fifty two years, 
 but cases are at times found in younger, and not in- 
 frequently in more elderly women. The softer, or en- 
 cephaloid variety, is more apt to occur in younger patients, 
 
31M) 
 
 MEDICAL AhD SURGICAL GYNiECOLOGY. 
 
 than scirrhua. As sciirhus is by far tlie most common 
 form found, it alono will be completely described. 
 
 Scirrhus usually commences as a small rounded firm 
 lump, which is at first movable, and commonly painless. 
 Its early growth is slow, but later it becomes hard, 
 nodular and less movable, or moving only with the entire 
 breast. The outlines of the growth are ill defined, 
 merging into surrounding mammary tissues and fat. Later 
 the tumor approaches the skin, causing dimpling, and then 
 
 puckering, while later still 
 
 the skin becomes densely 
 adherent, and finally may 
 ulcerate. This involve- 
 ment of the skin differs 
 considerably from that of 
 sarcoma or adenoma, for 
 while in them the skin is 
 first stretched and thinned 
 by pressure before ad- 
 hesion and ulceration oc- 
 cur, in cancer there is 
 puckering due to contraction of the newly formed fibrous 
 stroma in the invaded fibrous septa stretching from the 
 skin to the fascia covering the gland. The tumor sooner 
 or later, by downward extension, becomes adherent to the 
 pectoral muscle, and is then quite fixed. Later it may 
 infiltrate the muscle fibre, and even pass through the 
 intercostal spaces to the pleura. 
 
 The nipple commonly becomes retracted, the retraction 
 usually commencing somewhat sooner than the skin 
 dimpling. This retraction is due to the contraction of tlie 
 fibrous wulls of the milk ducts from invasion of their 
 walls by the growth. The retraction is a true one, not 
 like that occasionally seen in other tumor formations, 
 where the nipple lies buried by the tumor mass. It is to 
 be remembered that retraction of the nipple is not always 
 
 Fig. III. — Scirrhus carcinoma of the breast. 
 
DISEASES OF THE BREAST — NEOPLASMS. 397 
 
 present, and further that it is often a late sign. At times 
 a milky fluid can be expressed from the nipple, but this 
 symptom may also be present in adenoma. 
 
 Pain is absent in the early stages of growth, but later 
 becomes manifest, at first slight and stinging, but later 
 more severe sharp and cutting, and often shooting to the 
 axilla. This pain is almost constantly complained of, but 
 in rare cases entire absence of pain may be noted. 
 
 Ths axillary glands are affected early in the disease by 
 extension to them, through the lymphatics, of epithelial 
 cells from the breast nodule. These glands become en- 
 larged and tender, and though at first not palpable, later 
 appear as shoty nodules. The glands along the lower 
 border of the great pectoral muscle are first involved, and 
 later those about the axillary vessels and brachial plexus. 
 Owing to pressure on the axillary veins, oedema of the arm* 
 often follows, while pressure on the nerv( .^ will cause 
 severe neuralgic pain along their course. From the axillary 
 glands there may be extension to thoee above the clavicle. 
 In such cases the disease is usually considered to be 
 beyond operative interference. At times extension occurs 
 to the glands of the anterior mediastinum, and on the 
 right side, to the liver. General dissemination may occur 
 in the bones or viscera. In all cases of cancer of the 
 breast, a careful examination should always be made of 
 the axillary, supraclavicular, and anterior mediastinal 
 glands, and of the lungs and liver. 
 
 After adhesion of the tumor to the skin, little nodules 
 may develop there; and it, in its turn, will become red, 
 glazed and finally break down at some point. The skin all 
 about the ulcerated and adherent portion becomes puck- 
 ered and drawn towards it. In the ulcerated portions, a 
 protruding fungus rarely *orms; more commonly there 
 may be an ulcer with raised, everted, stony hard margins, 
 and a rough irregular sloughing base, which bleeds 
 readily. By the time the skin has ulcerated and the 
 
398 MEDICAL AND SURGICAL GYNJICOLOGY. 
 
 axillary glands have become enlarged, there will be develop- 
 ment of the cancerous cachexia. Death may be dne to 
 exhaustion from hemorrhage and local discharge, from 
 general dissemination of the growth, or from involvement 
 of a vital organ, or to some secondary infection or com- 
 plication. 
 
 Some exceptions should be made to these general state- 
 ments regarding scirrhus. In some rare cases the growth 
 may not begin as a localized nodule, but affects, as a 
 diffused growth, almost the entire breast. In some cases 
 known as atrophic or withering scirrhus found at times in 
 quite old women, the growth shows great shrinking and 
 density, and is of slow formation. This growth has not so 
 much tendency tc invade the glands, but general dissem- 
 ination may occur. 
 
 Cases of scirrhus of the breast, when untreated, have 
 an average course of thirty months; many cases do not 
 run more than eighteen months, while others may be pro- 
 longed for three or four years. 
 
 Encephaloid carcinoma is very rare, and runs a much 
 more rapid clinical course than scirrhus, a few weeks to 
 about fifteen months being the limit. It occurs as a !*ule 
 in younger patients, grows more rapidly, forming a large 
 tumor in a few months. It soon involves the skin and 
 glands, and rapidly disseminates in the internal organs or 
 bones. Occasionally it attacks both breasts at the same 
 time, and is then most rapidly fatal. 
 
 Colloid carcinoma is a carcinoma in which the 
 epithelial cells are undergoing colloid degeneration. 
 Such cancers are of slow growth, do not involve the glands 
 until late, and when removed have much less tendency to 
 recur than the other varieties. It is in fact much less 
 malignant. 
 
 Duct carcinoma or columnar-celled carcinoma origi- 
 nate s from the epithelium of the lactiferous ducts. The 
 gro\» th is thus found in the centre of the g'ind. Growth, 
 
DISEASES OF THE BREAST NEOPLASMS. 3<.M) 
 
 ns ft rule, is quite slow, the nipple is only occasionally re- 
 tracted. The axillary glands are involved but rather late 
 in its course. The growth, if left alone, reaches to and 
 involves the skin, leading to ulceration and the protrusion 
 of a fungous mass. When this form of carcinoma is freely 
 removed the tendency toward recurrence is slight. 
 
 Treatment and prognosis. In all cases at all amen- 
 able to treatment, there is but one method that can be 
 advised, and that is early and wide excision of the disease. 
 This will include amputation of the breasv and t)ie re- 
 moval of the axillary glands and pectoral fascia. This 
 operation of excision of the breast, with clearing out of 
 the axilla, is in itself not free from danger, but ranks as a 
 major operation, with a death rate of from three to ten per 
 cent. Needless to say the earlier and more radical the 
 operation, the better will be the result, so that operation 
 should always be undertaken as soon as a diagnosis has 
 been made. The common, early diagnostic signs of scirrhus 
 may be summarized as follows: — An ill defined, hard, and 
 usually painful lump, occurring in the periphery of the 
 gland, in a woman about the menopause, moving only with 
 the breast tissue, causing somewhat later retraction of the 
 nipple and dimpling of the skin, with early involvement 
 of the axillary glands, will prove to be scirrhus. All of 
 these features are of course not constantly found. 
 
 Dennis says: "The earlier the disease can be detected 
 and operated upon, the better the prognosis as regards 
 recurrence, and in a large number of cases the disease can 
 be diagnosticated at a time before glandular infection has 
 taken place; and if the tumor can be removed within six 
 months from its incipiency, and the axillaiy glands and 
 fatty tissue can be dissecti^l out, and likewise the pectoral 
 fascia and the peri-mammary and para-mammary areolar 
 tissue, the prognosis will yiekl brilliant results." 
 
 Wide infiltration of the skin, extensive adhesion to the 
 pectoral muscle or to the thoracic parietes, very large 
 
400 MEDICAL AND SURGKUL GYNJICOLOGY. 
 
 axillary glands or enlarged mediastinal glands, or involve- 
 ment of the supraclavicular glands, all tend to contra- 
 indicate operation with the hope of giving permanent 
 relief, but even in such, excituon of the breast and axillary 
 glands may at times be undertaken for the relief of the 
 local symptoms, and the prolongation of life. 
 
 In undertaking an operation for the eradication 
 of this disease, no partial one should be performed. 
 The rule must be, excise wide of all affected tissues, 
 remembering that there is an area of affected tissue out- 
 side those portions visibly affected. In all cases it is 
 necessary, too, to open up the axilla and eradicate the 
 glands and axillary fat. Further it is advisable in all 
 cases to remove the fascia covering the pectoralis major, 
 for it is in this fascia that the lymphatics lie which trans- 
 port the epithelial cells from the primary growth to their 
 secondarj^ seats of growth in the axilla. If the pectoralis 
 major muscle be involved superficially, the muscle must 
 be completely excised. One should not cut into the 
 tumor and then use the same knife, without careful 
 sterilization, to make further incisions. It is the epithe- 
 lial cells of the growth from which growth occurs, and 
 the opening up of the tumor and after use of the knife 
 might transfer these cells to the wound surface, where, 
 under favorable conditions, they would grow, reproducing 
 the carcinoma. 
 
 Recurrence of the growth after operation is the great- 
 est danger in carcinoma, and this danger is the greater 
 the later the operation is undertaken, or when the skin is 
 involved, or there is marked glandular involvement. 
 Dennis, carrying out his principles of early operation and 
 wide removal of the breast and lymph tracts, has had a 
 series of brilliant results. In his first series he had forty 
 three per cent of permanent recoveries after the three year 
 limit, with recurrence, either local, in glands, or in bones 
 or viscera, in the remainder. In his last series of cases he 
 
DISEASES OP THE BREAST— NEOPLASMS. 
 
 401 
 
 lins had one death, two local recurrences, and ten perman- 
 ent recoveries, two cases have not yet reached the limit 
 but are yet free from recurrence. No partial op-ration' 
 can claim these results, but it is well perhaps to remember 
 that these cases were, at least, moderately early in their 
 course. With partial or late operation, recurrence is the 
 rule, usually within a few months, either in the scar, in 
 the axilla, or internally. When possible, all recurrences 
 should be immediately excised, as removal holds out the 
 only hope. 
 
ihmhhi 
 
INDEX. 
 
 A. 
 
 Abdomen, examination of, 86 
 Abdominal hysterectomy, 273 
 
 pref,'nancy, S")? 
 Abortion, tubal, ,'<;")!> 
 AbHcesH, tubo-ovarian, 300 
 
 intraperitoneal, 316 
 
 pelvif3, 312 
 
 Abscess of vulvo- vaginal trlands, 
 
 138 *' 
 
 Absorbent cotton, ,52 
 Acne of vulva, 147 
 Aflonoma of breast, 389 
 Adeno-cur<rin()mu of uterus, 287 
 Adono-sarcoma of breast, 3!)(), 393 
 Adiposcere in e(;t()piegestation,36() 
 Ala vesportilionis, 13 
 Albumen water, 97 
 AI(!oliol in aiiii'sthesia, (57 
 Allis' inlialer, (i(i 
 
 Aloes, therapeutic use of, 88, 1 10 
 Alum, tlierupeutic use of, 81, 92 
 Amcnorrhoa, 1(17 
 
 after oopliore;!tomy, 108 
 
 an.emia and chlorosis in, 108 
 
 causes of, 108 
 
 definition of, 107 
 
 delayed puberty, l(t7 
 
 diai^nosis of, 1(»9 
 
 prinuiry, 107 
 
 primary permanent, 107 
 
 primary temporary, 107 
 
 secondary, 108 
 
 symptoms of, 108 
 
 treatnuiut of, 102, 109 
 Ammonium cliloride, 89 
 Anniulla, 28 
 
 Amyl nitrite in ana-sthesia, 68 
 Amt'sthetics, 62 
 
 a.c.e. mixture, 64 
 
 administration of, 64 
 
 Allis' inhaler, 66 
 
 choice of, 63 
 
 chloroform for, 66 
 
 closed etherization, 6."> 
 
 Clover's inhaler, 66 
 
 Anit'sthetics, ether for, 65 
 
 Eemarch's inhaler, 66 
 
 examination under, 7(i 
 
 niortality from, 62 
 
 open etli(!ri/.ati()n. 6.'> 
 
 Ormsby's inhaler, 66 
 Anal fascia, 36 
 Anal region, .38 
 Anatomy of |)elvic organs, 16 
 
 of breast, 380 
 Andro{;yno, 133 
 Angioma, urethral, 142 
 Anode, 101 
 Antellexion of uterus, 243 
 
 causes of, 244 
 
 symptoms of, 24r> 
 
 treatment of, 245 
 Antoversion of uterus, 242 
 
 causes of, 242 
 
 ofrerative measures for, 243 
 
 symptoms of, 242 
 
 treatment of, 243 
 Antisepsis, 43 
 Apiol, no, I IT) 
 Appendi(;itis, diagnosis from pelvic; 
 
 inflannnation, 316 
 Areolar hyperplasia of uterus, 235 
 Aristol, 92 
 
 Arsenic, therapeutic use of, II 1 1,") 
 Ascites, diagnosis from ovarian 
 
 cyst, 346 
 Ase))sis, 43, 45 
 Atresia of vagina, 127 
 
 of uterus, 21 1, 23!( 
 Axillary glands, anatomy of, 380 
 
 in cancer of breast, 397 
 
 B. 
 
 Bacillus coli commurn's, 43 
 Bacteria, pyogenic, 41 
 Balsam I'eru, 92 
 Bandages, 52 
 Bartholin's glands, 19 
 inflammation of, 146 
 Bassini's ojHsratioii, 134 
 Baths, hot, local, sitz, 90 
 
404 
 
 INDEX. 
 
 BiittoricH, Kivlviiiiic, fiiriuli( , 101 
 Boef ten after o|KMati()iiH, i(7 
 Bollmionim, !»'i, llH, 125 
 Bladdor, anatomy of, 32 
 nal(!uli of, 205 
 
 oystoHcopicr oxaminatioii of, H"> 
 digital (ixamiiiatioii of, H3 
 (loiil)le, 111") 
 exploration of, S3 
 exMtrophy of, IHr) 
 HBHine of, lJir> 
 foreiffn ImdicH in, 205 
 intlamniation of, 2(HI 
 injectionn into, 1>3 
 lif^aments of, 32 
 tnulforniabiotiH of, 195 
 neoplasms of, 200 
 ojHJiiings into, 32 
 jKJsition for oystoHcopy, 85 
 relations of, 32 
 trif^one of, 32 
 Blazius'o|ieration for vesico- vaginal 
 
 fistula, IS8 
 Boranic aoi<l, 45, 54, 92 
 Boring cancer of uterus, 277 
 Bozeman's operation for vesico- 
 vaginal fistula, IMS 
 Bre^vst, anatomy of, 3S1 
 blood supply of, 380 
 diseases of, 381 
 diseases of the nip[)le, 382 
 lymphatics of, 380 
 malformations of, 382 
 nerves of, 381 
 neuroses of, 383 
 Breast, inflammation of, 383 
 abscess of, 384 
 acute mastitis, 383 
 chronic mastitis, 385 
 cysts of, 387 
 Breast, neoplasms of, 388 
 adeno-sarcoma of, 394 
 adenoma of, 389 
 civrcinoma of, 394 
 classificaticn of, 388 
 colloid carcinoma of, 398 
 cystic adenoma of, 390 
 cystic sarcoma of, 393 
 encephaloid carcinoma of, 398 
 fibro-adenoma of, 390 
 papillary cystoma of, 390 
 proliferous cysts of, 300 
 sarcoma of, 393 
 scirrlius of, 396 
 
 Broad ligament, cysts of, 339 
 
 contents of, 340 
 
 incomplete o|K3ration in, 354 
 
 removal of, 353 
 
 unilo(;ular, 340 
 Broad ligament, thrombus of, 36fi 
 
 C. 
 
 C'alcification in ectopic gestation, 
 
 3(iO 
 Calcium chloride, 89 
 Cahuilus of bladtler, 205 
 Calomel, 88 
 Canal of Nuck, 2(5 
 Cancer, etl'ects onmenstruaMon, 108 
 Cannabis indica, 89, 118 
 (Jantharides, 91 
 (Jarbolic acid, 44, 92, 124, 146 
 ('arcinoma of bladder, 206 
 
 of cervix uteri. 278 
 
 encephaloid, of uterus, 278 
 
 of ovary, 355 
 Carcinoma of breast. 394 
 
 colloid, 398 
 
 columnar-(!elle<l, 398 
 
 duct, 398 
 
 encephaloid, 398 
 
 scirrhus, 396 
 
 prognosis of, 399 
 
 spheroidal-celled, .394 
 
 squamous-celled, .394 
 
 treatment of, 399 
 Caruncle, urethral, 142 
 Caruncuhi myrtiformis, 21 
 Cascara sag!'ada, 88 
 Catheter, Kelly's ureteral, 85 
 
 Mott's double current, 93 
 Cathode, 101 
 Cauliflower cancer, 277 
 (Jervical canal, dilatation of, 81 
 
 stenosis of, 103 
 Cervix, amputation of, 238, 282 
 ('ervix, cancer of, 277 
 
 amputation of cervix for, 282 
 
 causes of, 1:77 
 
 diagnosis of, 280 
 
 extension of, 278 
 
 hysterectomy for, 282, 286 
 
 jwilliative treatment for, 286 
 
 pathology of, 277 
 
 symptoms of, 279 
 
 treatment of, 281 
 
 varieties of, 277 
 Cervix, congenital auresia of, 211 
 
INDEX. 
 
 405 
 
 Cervix, cyHtM of, '_'«! 
 
 cyntio doj^oiienitioii of, "J-J? 
 ectropion of, 22ti 
 (/'ervix, oronioii of, •2'24, 22U 
 follicular, 2'.>» 
 papilliiry, 220 
 Himple, 225 
 Cervix, lacoriitioti of, 213 
 
 8arconiii of, 290 
 Chloroform, adiniiiiHtration of, 66 
 syinptoniM of dfinger in, 67 
 treatment of dangerous synip- 
 tomw, 67 
 Chloral hydrate, 1 18 
 Chlorosis and anainia, 108, 112, 
 
 116, 130 
 Cimicifiiga, 110, 117, 131 
 Clitoris, anatomy of, 18 
 malformations of, 132 
 Clitorideotomy, 129 
 Cocaine, 92 
 Cocjcygodynia, 1.")! 
 Coccyx, excision of, 152 
 Cci'liotomy, 271 
 
 abdominal incision in, 271 
 closure of abdominal incision in. 
 
 272 
 for genital tubercidosis, 377 
 for pelvic ha-matocele, .368 
 methods of suture in, 272 
 Clover's crutch, 1,)8 
 
 inhaler, 66 
 Cold, application of, 90 
 Colloid carcinoma, 398 
 Colpitis, 177 
 Colpo-cleisis, 191 
 Colpo-perineorrhaphy, 167 
 Colporrhaphy, 157 
 anterior, 157 
 Hegar's method, 158 
 Lefort's operation, 159 
 position for, 159 
 Sims' method, 157 
 Stoltz's method, 159 
 Commissures, 17, 18 
 Condylomata of vulva, 139 
 Connective tissue of pelvis, ,36 
 Constipation, jiost operative, 98 
 Copper sulphate, 92, 146 
 Corpus cavernosum, 18 
 Corpus luteum, 31 
 Corrosive sublimate, 44 
 Corpus uteri, cancer of, 287 
 diagnosis of, 288 
 
 Corpus uteri, cancer of, treatment, 
 289 
 
 varieties of, 287 
 Cracked nipples, 382 
 ('urettoM, 83, 94 
 Curetting, 94 
 Cystitis, 201 
 
 a(nite, 200 
 
 causes of, 200 
 
 chronic, 200 
 
 Emmet's button-hole oiKsration 
 
 for, 205 
 operative treatment for, 205 
 pathology of, 200 
 symptoms of, 201 
 treatment of, 202, 204 
 Cystocele, 155 
 
 causes of, 1,55, 256 
 complication?, of, 156 
 treatment of, 1;.;!, 171 
 Cysto-sarcoma of bre.st, 3!)3 
 
 of uterus, 29(t 
 Cystoscope, 85, 189 
 Cysts of the breast, .387 
 retention, 387 
 serous, 387 
 treatment of, 388 
 Cysts of cervical canal, 261 
 of vagina, 182 
 of vulvo-vaginal glands, 1.38 
 Cysts of ovary, 331 
 dermoid, 337 
 follicular, .3.S1 
 
 glandular proliferating, 333 
 papillary proliferating, 336 
 parovarian, .339 
 supra-tubal, 332 
 tubo-ovarian, 331 
 
 O. 
 
 Depressor, vaginal, 79 
 
 Diabetes, effects on menstruation, 
 
 108 
 Diagnotfis in general, 68 
 Dietary, post operative, 97 
 Digitalis. 68, 112 
 Dilators, uterine, 82 
 
 Ellinger's, 82 
 
 glass, 129 
 
 (ioodelKe, 82 
 
 Hanks', 82 
 
 VVylie's, 82 
 Diplococcus pneumoniie, 42 
 Discus proliferus, 30 
 
im 
 
 INDEX. 
 
 Diseusf of special rej^ioiiH, 132 
 Disiiifc^ction, (^liomiciil, 44 
 
 of Held of opei'iitioii, 47 
 
 of hands, 4") 
 Dorsal position, 76 
 Douthes, 90, 91 
 
 iiitra-tifceriiie, 93 
 Douglas' potu^h, 34 
 Drainage, iodoform gauze for, 53 
 
 nietliods for, r)3 
 
 reasons for, '}'3 
 
 tubes, 53 
 Dressings, 51 
 
 preparation of, 52 
 Dj'snienorrho'a, 1 1'l 
 Dysmenorrhd'a, e,,'igeHtive or in- 
 Hanimatory, 118 
 
 causes of, 119 
 
 definition of, 118 
 
 iliagnosis of, 1 19 
 
 symptoms of, 1 19 
 
 tieatment of, 120 
 Dysnienorrhiea, ineuibraiious, 122 
 
 character of disiiharge in, 122 
 
 chfira(!ter of pain in, 123 
 
 curetting in, 124 
 
 diagnosis of, from early abortion, 
 123 
 
 dilatation of cervix for, 124 
 
 galvanization for, 1(13, 124 
 
 menstrual decidua in, 122 
 
 microscopical examination in, 
 122 
 
 pathology of, 122 
 
 symptoms of, 123 
 
 treatment of, 124 
 Dysmenorrliu'a, neuralgic. iKi 
 
 causes of, 1 1(5 
 
 definition of, IKi 
 
 symptoms of, 1 17 
 
 treatment of, 1 17 
 
 use of drugs in, 1 17 
 Dysmenorrhd'a, obstru('tive, 120 
 
 causes of, 121 
 
 character of pain in, 12! 
 
 dihitation of cervix in, 122 
 
 flexions as a cause, 121 
 
 pin-iiole OS as a cause, 121 
 
 poh ,.>! and fibroids as causes, 
 121 . 
 
 symptoms ot, 121 
 
 treatment of, 122 
 
 use of stem pessary i!i, 122 
 DysineiiorrlKt'a, ovarian, 124 
 
 I)ysmenorrh(pa, ovarian, causes of, 
 124 
 dironic ovaritis in, 124 
 prolapse of ovary in, 124 
 treatment of, 124 
 Dj'smenorrhd'a, treatment of mixed 
 
 form, 126 
 Dyspareunia, 73, 127 
 
 Ectopic gestation, 35(1 
 
 abdominal, 358 
 
 ampullar, 357 
 
 changes in fatus after death in, 
 360 
 
 classification, 357 
 
 diagnosis of, 362 
 
 etiology of, 356 
 
 evai.aation of gestation sac 
 through vagina, 356 
 
 interstitial, 357 
 
 life of foetus in, 359 
 
 operation for, 364 
 
 primary, 357 
 
 rupture of sa(! in, 357, 361 
 
 secondary, 357 
 
 symjjtoms of, 360 
 
 tubal, 358 
 
 treatment of, at time of rupture, 
 363 
 
 treatment of, before ru[)ture,362 
 Fctropion of cervix uteri, 215, 226 
 Kczcnia of vulva, 147 
 
 diagnosis from herpes, 148 
 Electricity, a|>i)li(;ation of, 100 
 
 articles necessary for, 101 
 
 faradic, or indirect current, 102 
 
 galvanic, or direct current, 101 
 Electrodes, lOl 
 
 Apostoli's, 101 
 
 bipolar, 101 
 
 Engelman's, 101 
 
 large and small, 102 
 
 Martin's, 101 
 
 thera|ieutic ett'ectsof, 103 
 Elepliantiasis of vulva, 140 
 Elytritis, 177 
 Elytrorrhajjhy, 157 
 Enuiiet's button -hole oj)eration, 205 
 
 operation for fecal fistula, 193 
 
 perineorrhaphy, 1()9 
 
 tiachelorrhaphy needles, 217 
 Encephaloid carcinonui, 398 
 Endocervicitis, 224 
 
INDEX. 
 
 407 
 
 Kndocervioiti.s, cdiise.f of, •J.'J.'t 
 cystic (legenenitioii in, 227 
 cliagii(),si.>< of, 227 
 eversion or ectio|)ioii in, 22(i 
 folliciilfir eroHion in, 22(5 
 lociil jippliuatioiis for, 228 
 opyrutive treatment for, 229 
 I)apilliiiy erosion in, 226 
 patholof^y of, 22o 
 symptoms of, 227 
 treatment of, 227 
 Ehflometritis, acute, 219 
 
 associated with metritis, 219,221 
 causes of, 220 
 diajrnosis of, 222 
 follow inir abortion or labor, 222 
 hysterectomy for, 223 
 pathology of, 220 
 prognosis of, 222 
 septic infection in, 222 
 streptococcus antitoxine in, 224 
 symiitonis of, 221 
 treatment of, 223 
 treatment of septic form, 223 
 Eulometritis, chronic corporeal, 
 229 
 causes of, 230 
 diagnosis of, 233 
 glandular, 230 
 interstitial, 230 
 pathology of, 230 
 I)hysical signs of, 233 
 I)rognosis of, 233 
 symptoms of, 232 
 treatment of, 104, llf), 234 
 Endometritis decidualis, 231 
 Endoscope, .Skene's, 83 
 Enterocele, lot! 
 causes of, Irili 
 formation of, 153, 155 
 treatment of, 156, 171 
 Epispadias, 132 
 Episio-cleisis, 191 
 E|)ithelioma of bladder, 206 
 of breast, 394 
 of ovary, 354 
 of uterus, 278, 287 
 atypical, of cervix, 278 
 cylindrical, of cervix, 278 
 pavement, of cervix, 278 
 Hcjuamous, of cervix, 278 
 Erect position for physical exam- 
 ination, 76 
 Ergot, tiierapeutic use of, 88, 113 
 
 Eruptive diseases of vulva, 147 
 Eryt.'iema of vulva, 147 
 Er^'sipelas of vulva, 147 
 Esmarch's inhaler, (>" 
 Etiology of diseases of women, 57 
 airest of development, 57 
 bacteria] a(;tion, 57 
 congenital doticiencies, 57 
 constitutional defects, 59 
 education, 60 
 infectious diseases, 61 
 operative causes, 62 
 sexual exhaustion, 61 
 Ether, ad'.iinistration of, 65 
 danger.ri of, 66 
 
 treatment of dangerous symp- 
 toms, 67 
 Examination, form for recording, 
 
 69 
 Examination of natient, (»8 
 
 abnormal varieties of menstrua- 
 tion in, 72, 74 
 history of patient 'n, 70 
 menstrual history in, 70 
 obstetric history in, 72 
 physical examination, 75 
 tumors and swellings in, 74 
 urinary and intestinal symjitoms 
 in, 75 
 Examination, methods of, 77 
 bimanual, 78 
 digital, 77 
 instrumental, 78 
 rectal, 78 
 vaginal, 77 
 visual, 77 
 Examination, position for, 7G 
 dorsal, 76 
 erect, 76 
 
 genu-pectoral, 76 
 Sims', 76 
 
 Treiidelenlwrg, 76 
 Exanthenmta, etl'ects of, 61, 112 
 Exstrophy of bladder, 195 
 Extra-peritoneal ha'inatocele, 365 
 Extra-uterine pregnancy, 365 
 
 F. 
 
 Fallopian tubes, 28 
 ampulla of, 28 
 developuient of, 14 
 diseases of, 292 
 fimbria' of, 28 
 limbria ovurica of, 28 
 
408 
 
 INDEX. 
 
 Fallopian tubes, infundibulutn of, 
 28 
 
 isthmus of, 28 
 
 malformations of, 292 
 
 ostium abdominale of, 28 
 
 ostium internum of, 28 
 
 structure of, 29 
 Fallopian tubes, inflammation of, 
 292 
 
 acute catarrhal, 293 
 
 acute purulent, 293 
 
 atrophy of, 306 
 
 hydrosalpinx, 304 
 
 interstitial salpingitis, 294 
 
 prognosis of, 298 
 
 pyosalpinx, 302 
 
 salpingo-oophorectomy for, 300 
 
 symptoms of, 295 
 
 treatment of, 299 
 
 tubo-ovarian abscess, 306 
 Faradism, 102 
 Fascia, anal, 36 
 
 deep perineal, 38 
 
 ischio-rectal, 36 
 
 obturator, 36 
 
 [»elvic, 36 
 
 perineal, 38 
 
 rectovesical, 36 
 Fibro-adenoma of breast, 390 
 Fibro-myoma of uterus, 261 
 Fibro-sarcoma of uterus, 289 
 Fibroids of uterus, 261 
 
 alterations and degenerations in, 
 265 
 
 course of, 266 
 ■ diagnosis of, 267, 347 
 
 etiology of, 265 
 
 hysterectomy for, 271 
 
 ligature of uterine arteries for, 
 269 
 
 myomectomy for, 271 
 
 oophorectomy for, 270 
 
 structure of, 263 
 
 trf itment of, 105, 268 
 
 UP J of ergjt in, 268 
 
 varieties of, 262 
 Fibroma of bladder, 206 
 
 of ovary, 354 
 
 of vagina, 183 
 
 of vulva, 140 
 Fistula, fecal, 192 
 
 causes of, 192 
 
 operative relief for, 193 
 
 situation of, 192 
 
 Fistula, fecal, symptoms of, 192 
 
 treatment of, 192 
 
 varieties of, 192 
 Fistula, genital, 184 
 
 causes of, 184 
 
 definition of, 184 
 
 varieties of, 184 
 Fistula, urethrovaginal, 188 
 Fistula, uretero-vaginal, 189 
 
 causes of, 189 
 
 ca'liotomy for, 190 
 
 cystoscopic examination in, 189 
 
 implantation of ureter for, 190 
 
 situa*^ion of, 189 
 
 vaginal operations for, 190 
 Fistula, urinary, indirect methods 
 
 for relief of, 191 
 Fistula vesicouterine, 188 
 
 diagnosis of, 188 
 
 location of, 188 
 
 treatment of, 188 
 Fistula, vesi CO- utero- vaginal, 189 
 Fistula, vesico- vaginal, 184 
 
 Blazius' o{)eration for, 188 
 
 Bozeman's o{)eration for, 188 
 
 causes of, 184 
 
 detection of, 185 
 
 location of, 184 
 
 Simon's oj)eration for, 188 
 
 Sims' operation for, 186 
 
 Tait's operation for, 188 
 Follicular oophoritis, 326 
 Form for case taking, 69 
 Fossa navicularis, 18 
 Fourchette, 18 
 Frenum clitoridis, 18 
 Functional diseases, 107 
 
 G. 
 
 Galvanism, 101 
 
 thera{>eutic effects of, 102 
 (ialvanometer, 101 
 Gastrotomy, 2V1 
 Gauzes, 52 
 
 (Jehrung's j)essary, 240 
 (Jenital cord, 14 
 Genital fistulaj, 184 
 (ienital folds, 15 
 Genital tubercle, 15 
 (ienital tuberculosis, 371 
 
 diagnosis of, 375 
 
 etiology of, 371 
 
 of ovaries, 374 
 
 primary, 371 
 
INDEX. 
 
 409 
 
 Oenital tuberculosis, proytiosis of, 
 376 
 secondary, 371 
 symptoms of, 374 
 treatment of, 376 
 of tubes, 373 
 of uterus, 372 
 of vagina, 372 
 of vulva, 371 
 Genitals, development of, 12 
 
 anatomy of, 16 
 Genu-pectoral position, 76 
 (terminal spot, 31 
 (Jerminal vesicle, 31 
 Olands, axillary, anatomy of, 380 
 
 in cancer of breas^, 397 
 Glans clitoridis, 18 
 Glycerine, 91 
 Gonococcus, 42 
 Gonorrhtta, 127 
 Gonorrhreal vulvitis, 145 
 diagnosis of, 145 
 treatment of, 146 
 Goodell's dilator, 82 
 Gossypium, 89 
 
 Gout, effects on menstruation, 116 
 (iuaiacum, 110, 117 
 Gynandria, 133 
 Gynecological techni(|ue, 40 
 
 H. 
 
 Hands, disinfection of, 45 
 Hank's dilator, 82 
 Hamamelis, 89, 113 
 Hiumatocele of canal of Nuck, 135 
 pelvic, 365 
 
 pudendal, 136 
 Hiematocolpos, 171, 175 
 
 dangers from, 172 
 
 mode of formation of, 171 
 
 symptoms of, 172 
 
 treatment o*^, 173 
 Hajmatoma of ovaries, 324 
 
 pelvic, 369 
 
 of round ligament, 135 
 Hiematometra, 172, 175 
 
 dangers from, 172 
 
 definition of, 172 
 
 diagnosis from ovarian cyst, 347 
 
 mode of formation, 172 
 
 symptoms of, 172 
 
 treatment of, 173 
 Ha'matosalpinx, 172, 305 
 
 diagnosis of, 308 
 
 HjL'mat()8aii)inx, sym[)toms of, 307 
 treatment of, 308 
 varieties of, 305 
 Heat, external application of, 90 
 Hemaphrodism, 133 
 androgyne, 133 
 gynanclria, 133 
 treatment of, 134 
 true and spurious, 133 
 Hemorrhage, post operative, 99 
 symptoms of, 99 
 treatment of, 99 
 Hemorrhage, pudendal, 136 
 Hernia, inguino-labial, 134 
 diagnosis of, 134 
 radical operation for, 134 
 situation of, 134 
 treatment of, 134 
 Hernia, vaginolabial, 134 
 method of production, 134 
 situation of, 134 
 treatment of, 134 
 Hernia, vulvar, 134 
 
 varieties of, 134 
 Hegar's anterior colporrhaphy, 158 
 colpo-perineorrhaphy, 167 
 method of amputation of cervix, 
 241 
 Herjies progenitalif, 148 
 diagnosis from chancre, 148 
 diagnosis from eczema, 148 
 treatment of, 148 
 Hydatid of Morgagni, cysts of, 331 
 Hydrastis Canadensis, 89, 131 
 Hydrocele, 135 
 
 diagnosis from hernia, 135 
 situation of, 135 
 treatment of, 135 
 Hydronephrosis, diagnosis from 
 
 ovarian cysts, 347 
 Hygiene, general, 87 
 Hydrosalpinx, 304 
 diagnosis of, 308 
 pathology of, 304 
 symptoms of, 307 
 treatment of, 308 
 Hymen, absence of, 171 
 
 anatomy of, 21 
 Hymen, atresia of, 171 
 dangers arising from, 173 
 diagnosis of, 172 
 hicmatocolpos from, 171 
 ha'inatometra from, 172 
 hivmatosalpinx from, 172 
 
410 
 
 INuEX. 
 
 \ 
 
 Hymen, atresia of, symptoms of, 
 172 
 
 treatment of, 173 
 Hymen, imperforate, 171 
 
 malformations of, 171 
 
 varietiep of, 20, 171 
 Hyijenimia of ovary, 324 
 Hypentsthesia of vulva, 150 
 
 pathology of, loO 
 
 treatment of, 151 
 Hyijertrophy of uterus, 240 
 Hysterectomy, abdominal, 273 
 
 complete, 276 
 
 extra-peritoneal treatment of the 
 stump in, 274 
 
 indications for, 273 
 
 intra-peritoneal treatment of the 
 stump in, 275 
 
 partial, 273 
 
 varieties of, 273 
 Hysterectomj', vaginal, 286 
 
 by clamps, 285 
 
 by ligatures, 283 
 Hysterectomy sacral, 286 
 Hysteropexy abdominal, 253 
 
 vaginal, 2o2 
 
 I. 
 
 Ichthyol, 91, 92 
 Infundibulum, 28 
 Injuries of vulva, 136 
 Instruments, list of, 55 
 
 for cii'liotoniy, 55 
 
 for dilatation of cervix and cur- 
 etting, 56 
 
 for operations outside of hospi- 
 tals, 56 
 
 for trachelorrhaphy, 56 
 
 for perineorrhaphy, 55 
 
 for vaginal hysterectomy, 55 
 Interfollicular oophoritis, 326 
 Interstitial oophoritis, 326 
 Intra-ligamentous fibroma of uter- 
 us, 262 
 Intra-{)eritoneal hfumatocele, 365 
 Introductory, 9 
 Inversion of uterus, 257 
 
 causes of, 258 
 
 diagnosis of, 258 
 
 instrumental treatment of, 260 
 
 manual treatment of, 259 
 
 operative treatment of, 260 
 
 symptoms of, 258 
 
 varieties of, ' '7 - - . 
 
 Iodine, 90, 92 
 
 Iron, thera|jeutic use of, 110, 117 
 
 in amenorrhua, 110 
 
 in monorrhagia, 115 
 
 in metrorrhagia, 115 
 
 in neuralgic dysmenorrhd-a, 117 
 Iodoform gauze, prejMiration of, 52 
 
 powder, 54 
 Irrigating fluids, 53 
 
 normal salt solution, 54 
 
 selection of, 54 
 
 temperature of, 54 
 Irrigation during operations, 53 
 
 of bladder, 93 
 
 of uterus, 93 
 
 K. 
 
 Kangaroo tendon, 51 
 Kelly's method for examination of 
 bladder, 85 
 for ureteral catheterization, 85 
 Koeberle's serre-nu-ud, 273 
 Kraske's operation for hysterec- 
 tomy, 286 
 Kraurosis vulvit;, 151 
 
 L. 
 
 Labarracque's solution, 46 
 Labia majora, structure of, 17 
 Labia minora, structure of, 18 
 Laparotomy, 271 
 Lefort's oi)eration for prolapse of 
 
 vagina, 159 
 Leucorrhd'a, 72, 129 
 
 appearance of discharge, 130 
 
 etiology, 130 
 
 idiopathic, 130 
 
 symptoms of, 130 
 
 symptomatic, 130 
 
 treatment of, 131 
 Lichen of vulva, 147 
 Ligaments, broad, 25 
 
 of bladder, 32 
 
 ischio-perineal, 38 
 
 ovarian, 13, 29 
 
 perineal, 38 - 
 
 round, 25 
 
 sacro-sciatic, 16 
 
 sacr. iterine, 25 
 
 triangular, 38 
 
 uterine, 24 -^ 
 
 vesico-uterine, 24, 32 ' 
 
 Ligatures, choice of, 48 
 Liquor folliculi, 30 
 
INDEX. 
 
 411 
 
 Lithoijedian, 360 
 Lupus of vulva, 141 
 Lyniphutice of breast, 380 
 Lvsol, 92 
 
 w. 
 
 Magnesia sulphate, 88 
 
 Malaria, effects on menstruation. 
 
 108, 112, 116 
 Malformations of bladder, 195 
 of breast, 382 
 of hymen, 171 
 of ovaries, 320 
 of tubes, 292 
 oi urethra, 194 
 of Uu'M-us, 207 
 of vagina, 173 
 of vulva, 1.32 
 Malignant deciduoma, 290 
 
 peritonitis, 379 
 Mammary abscess, ,384 
 
 cysts, 390 
 Manganese binoxide. 111 
 Mastitis, acute, 383 
 l)athology of, 384 
 symptoms of, 383 
 treatment of, 38") 
 Mastitis, chronic, 385 
 interstitial, 385 
 pathology of, 386 
 treatment of, 387 
 Meatus urinarius, 18, 31 
 Membrana granulosa, .30 
 Menopause, 72, 113 
 Menorrhagia and metrorrhagia, 1 12 
 action of eigot, digitalis, ham- 
 
 amelis and hydrastis in, 11 
 action of iron and arsenic in, 
 
 112, 115 
 causes of, 112 
 curetting for, 114 
 definition of, 1 12 
 galvanization for, 104, 115 
 treatment of, 113 
 use of hot water in, 114 
 use of tampons in, 114 
 Menstrual decidua, 122 
 Menstruation, 70 
 abnormal varieties of, 72 
 age of commencement of, 71 
 atteiu'ant symptoms of, 71 
 daily amount of discharge, 71 
 delayed, 107, 109 
 disorders of, 107 
 
 Menstruation, duration of flow, 71 
 precocious, 115 
 rhythm of flow, 71 
 vicarious. 111 
 Mercury bichloride, 44, 91, 146 
 Mesosalpinx, 13 
 Mesovarium, 13 
 Metritis, acute, 219 
 exanthematous, 219 
 fungous, 219 
 granular, 219 
 gonorrheal, 219 
 traumatic, 219 
 post-puerperal, 219 
 puerperal, 219 
 ulcerating, 219 
 Metritis, chronic, 235 
 etiology of, 235 
 pathology of, 235 
 symptoms of, 236 
 synonyms of, 235 
 treatment of, 237 
 Metritis, chronic endometritis, 229 
 Metrorrhagia, 112 
 Micrococcus lanceolatus, 42 
 Milk, post-operative use of, 97 
 
 peptonized, 97 
 Mineral waters, use of, 88 
 Mens Veneris, structure of, 17 
 Morphia, post operative use of, 98 
 Mullerian ducts, 13 
 Muscle, bulbo-cavernosus, 38 
 coccygeus, 37 
 compressor urethra', 31, 39 
 constrictor vagina-, 19, 39 
 erector clitoridis, .38 
 ischio-cavernosus, 38 
 levator ani, 34, 37 
 transversus perinei, deep, 39 
 transversus i)erinei, superficial, 
 
 39 
 sphincter ani, .34 
 sphincter vagina-, .34, 38 
 
 Mummification inectopicirestation 
 360 
 
 Myo-fibroma of uterus, 261 
 
 Myoma of bladder, 206 
 
 of uterus, 261 
 
 of vulva, 140 
 Myomectomy, 271 
 
 N. 
 Nabothian glands, 23, 227 
 Naphthol, 45 
 
412 
 
 INDEX. 
 
 Neoplasms of bladder, 206 
 
 of breast, 3MH 
 
 of uterus, benign, 2(51 
 
 of uterus, malignant, 276 
 
 of vagina, 182 
 Neuralgia, ovarian, 105 
 
 {)elvic, 105 
 Neuralgic dysmenorrhd'a, 116 
 Neuroma of vulva, 141 
 Neuroses of breast, 383 
 Nipple, diseases of, 382 
 
 fissures of, 382 
 
 inflammation of, 382 
 Nuok, caiuil of, 26, 135 
 Nux vomica, 117 
 Nymphif, 18 
 Nymphonumia, 128 
 
 causes of, 128 
 
 definition of, 128 
 
 treatment of, 128 
 
 O. 
 
 Obstetric history of patient, 72 
 Obturator pouch, 35 
 Oophorectomy, 125, 300, 302 
 Oophoritis, acute, 326 
 
 course of, 327 
 
 etiology of, 326 
 
 symptoms of, 327 
 
 treatment of, 328 
 Oophoritis, chronic, 328 
 
 etiology of, 329 
 
 symptoms of, 329 
 
 treatment of, 105, 330 
 Operating suits, 45 
 Organs cf generation, 17 
 Ormsby inhaler, 66 
 Ostium abdominale, 28 
 
 internum, 28 
 Ovarian cysts, 331 
 
 abdominal stage of, 343 
 
 accidents and complications in, 
 341 
 
 diagnosis of, 345 
 
 pedicle in, 341 
 
 pelvic stage of, 342 
 
 prognosis of, 344 
 
 treatment of, 348 
 Ovaries, at. ,ihy of, 328 
 
 cystic degeneration of, 328 
 Ovaries, cysts of, 331 
 
 classification of, 331 
 
 etiology of, 339 
 Ovaries, dermoid cysts of, 337 
 
 Ovaries, dermoid cysts of, contents 
 of, 338 
 
 mode of origin of, 339 
 Ovaries, development of, 13 
 
 anatomy of, 29 
 
 structure of, 29 
 Ovaries, diseases of, 320 
 Ovaries, dis{)lacements of, 321 
 
 acijuired, 321 
 
 congenital, 321 
 Ovaries, liy[)eriemia and hajmatoma 
 of, 324 
 
 etiology of, 325 
 
 symptoms of, 325 
 
 treatment of, 325 
 Ovaries, malformations of , 320 
 
 neoplasms of, 330 
 Ovariotomy, 348 
 
 accidents during, 352 
 
 delivery of cyst in, 349 
 
 for broad ligament cysts, 353 
 
 history of, 349 
 
 incomplete operation in, .i54 
 
 methods of operating in, 359 
 Ovary, cysts of the corpus luteum, 
 333 
 
 cyst of the hvdatid of Morgagni, 
 332 
 
 follicular cysts of, 333 
 
 hirge cysts of, 333 
 
 microcysts of broad ligament, 
 332 
 
 small residual cysts of, 331 
 
 supra-tubal cysts, 332 
 
 tubo-ovarian cysts, 333 
 Ovary, hernia of, 323 
 
 varieties of, 323 
 
 radical oi)eration for, 324 
 Ovary, prolapse of, 322 
 
 causes ot, 322 
 
 diagnosis of, 323 
 
 symi)toms of, 323 
 
 treatment of, 323 
 Ovary, jnoliferating glandular 
 cysts of, 333 
 
 (contents of, 335 
 
 formation of, 334 
 
 origin of, 337 
 Ovary, proliferating papillary cysts 
 of, 336 
 
 contents of, 335 
 
 formation of, 336 
 
 origin of, 337 
 Ovary, tuberculosis of, 374 
 
INDEX. 
 
 418 
 
 Ovary, solid tumors of, 354 
 
 carcinoma, 3").") 
 
 epithelioma, 3r)5 
 
 fibroma, S'>i 
 
 treatment of, 355 
 Ovum, structure of, 39 
 
 P. 
 
 Paget's disease, 394 
 
 Papillary cystoma of breast, 390 
 
 Pupdloma of bladder, 2(J(5 
 
 of vulva, 139 
 Parametritis, 104, 310 
 Parametrium, 25, 36 
 Parasites, cause of pruritus, 149 
 Para-uterine pouch, 35 
 Para-vesical pouch, 35 
 Parenchymatous cancer of uterus. 
 
 277 
 Parenchymatous metritis, 235 
 Paroophoron, 25, 31 
 Parovarium, 13, 25, 31 
 
 cysts of, 339 
 Patient, i)reparation of, for opera- 
 tion, 46 
 Pedicle in ovarian cysts, 351 
 
 ligature of, 351 
 Pelvic abscess, 312 
 extension of, 312 
 situation of, 312 
 treatment of, 312 
 Pelvic diaphragm, 37 
 functions of, 37 
 muscles of, 37 
 Pelvic floor, anatomy of, 36, 153 
 functions of, 1.53 
 lesions of, 1,52, 171 
 Pelvic floor, causes of weakness of, 
 153 
 constitutional, 153 
 laceration, 154 
 over distension, 153 
 senile atrophy, 154 
 subinvolution, 1,54 
 Pelvic Hoor, conditions associated 
 with lesions of, 154 
 cystocele, 155 
 enterocele, 156 
 prolai)se of vagina, 155 
 rectocele, 156 
 Pelvic floor, treatment of lesions 
 of, 1,56 
 colporrhaphy in, 157, 1.59 
 local astringents in, 156 
 
 Pelvic floor, treatment of lesions 
 of, perineorrhaphv in, 160 
 supplementary suppoits in, 156 
 suigieal methods in, 157, 171 
 tampons in, 156 
 Pelvic hii-matocele, 365 
 causes of, 366 
 Cd'liotomy for, 3().S 
 diagnosis of, 367 
 formation of, 366 
 symptoms of, 36(i 
 termination of, 367 
 treatment of, 36.S 
 Pelvic ha-matoma, 3(i9 
 etiology of, 369 
 pathology of, 3(59 
 symptoms of, 370 
 treatment of, 370 
 Pelvic inflammation, 309 
 Pelvic lymphangitis, 31(» 
 Pelvic peritonitis, 128, 315 
 diagnosis of, 318 
 etiology of, 315 
 
 intraperitoneal abscess in 316 
 pathology of, 316 ' 
 
 prognosis of, 319 
 treiitment of, 319 
 Pelvic peritoneum, .35 
 Perimetritis, 104, 315 
 Perineal body, 39, 153 
 fascia, 38 
 ligaments, 38 
 muscles, 38, 1,52 
 region, 38 
 Perineorrhapliy, 160 
 
 for complete rupture, 163 
 control of hemorrhage in, 16'' 
 denudation in, 161 
 Emmet's operation, 169 
 Hegar's operation, 167 
 for incomplete rupture, 161 
 for rui)ture of recto-v;iginal sep- 
 tum, 164 
 
 sutuitJi^ in, 162 
 
 Tait's operation, 165 
 Perineum, craise of loss of power 
 of, 153 
 
 laceration, 154 
 
 ovei' destension, 153 
 
 senile atrophy, 1.54 
 
 subinvolution, 154 
 Perineum, laceration of, 160 
 
 effects of, 160 
 
 varieties of, 160 
 
414 
 
 INDEX. 
 
 Perineum, results of loss of power 
 of, ISf) 
 
 cystocele, l^H 
 
 eufcerocele, ITHS 
 
 prolapse of viiffina.. 155 
 
 rectocele, 155 
 Perineum, blood supply of, 40 
 
 functions of, 153 
 
 nerve supply of, 40 
 
 structure of, S9 
 Perioophoritis, 315, 326 
 Perisalinngitis, 315 
 Peritoneum, pelvic, 35 
 Peritonitis, tubercular, 346 
 
 diagnosis from ovarian cysts, 346 
 Peri-uterine phlegmon, 310 
 Permanganate gauze, 52 
 Phenacetine, 1 18 
 Phenol, 92 
 Phlegmonous inflammation of 
 
 vulva, 137 
 Phosphorus, 117 
 Plastic operations, post-operative 
 
 treatment of, 100 
 Plethora, effects on menstruation, 
 
 1(»S, 116 I 
 
 Plumbi acetatis, 01, 146 
 Pole changers, 1(H 
 Poles of battery, 101 
 Polypoid flbromaof uterus, 262, 270 
 Polypus, uterine, 261 
 
 vaginal, 183 
 Post-o{jerative treatment, 96 
 Potassium permanganate, 45, 111, 
 
 146 
 Powder for dressings, 54 
 Pregnancy, extia-uterine, 356 
 
 abdominal, 357 
 
 ovarian, 357 
 
 tubal, 357 
 Prepuce, 18 
 Procidentia uteri, 255 
 I'rolapsus urethra', 142 
 Prolapsus uteri, 254 
 
 causes of, 255 
 
 complications of, 255 
 
 symptoms of, 256 
 
 treatment of, 256 
 Pruritus vulvio, 148 
 
 causes of, 149 
 
 clinical appearance of, 148 
 
 [Mithology of, 149 
 
 symptoms of, 149 
 
 treatment of, 149 
 
 Puberty, delayed, 107 
 Pudendal hn'matocele, 136 
 Puflendal hemorrhage, 136 
 Pulsatilla, 110, 118 
 Purgatives, 87 
 Pyii-mia, 41 
 Pyosalpinx, 302 
 
 definition of, 302 
 
 diagnosis of, 308 
 
 l)atiiology of, 303 
 
 symptoms of, 307 
 
 termination of, 304 
 
 treatment of, 308 
 
 R. 
 
 Rectocele, 156 
 
 mode of formation, 153, 155, 256 
 
 complications of, 156 
 
 treatment of, 156, 171 
 Recto-uterine j)ouch, 35 
 Rectum, structure of, 34 
 
 muscles of, 34 
 
 relations of, 34 
 Retro-ovarian shelves, 35 
 Resolvents, 90 
 
 Restlessness after oi»eration, 98 
 Retroversion and retroflexion of 
 uterus, 246 
 
 causes of, 246 
 
 operative treatment for, 252 
 
 shortening round ligaments for, 
 252 
 
 symptoms of, 246 
 
 treatment of, 249 
 
 use of pessaries in, 249 
 
 vaginal fixation for, 252 
 
 ventral fixation for, 253 
 Rheophores, 101 
 Rheostats, 101 
 
 Rheumatism, effects on menstrua- 
 tion, 116 
 Rosenmuller's organ, 13, 21 
 
 S. 
 
 Salicylates, 110 
 Salicylic acid, 45, 146 
 Salpingitis, 292 
 
 acute catarrhal, 293 
 
 acute jHirulent, 293 
 
 interstitial, 294 
 
 prognosis of, 298 
 
 salpingo-oophorectomy for, 300 
 
 symptoms of, 295 
 
 treatment of, 104, 298 
 
INDEX. 
 
 415 
 
 Salpiiifro-oophorectomy, 3()0 
 abdominal, IM) 
 vaginal, 302 
 Salt solution, normal, 54 
 Sapni'inia, 41 
 Saifjonia botryoideM, 290 
 Sarcoma of breast, Hm 
 of ovary, 355 
 
 uteri ileciduo-cellulare, 290 
 Sarcoma of uterus, 289 
 diagnosis of, 291 
 symptoms and course of, 290 
 treatment of, 291 
 varieties of, 2S9 
 Sarcoma of vulva, 141 
 Schroeder's method for amputation 
 
 of cervix, 239, 241 
 Scirrhus of breast, 396 
 adhesion of skin in, 396 
 axillary glands, infection in, 
 
 397 
 axillary glands, removal in, 400 
 pathology of, 39G 
 retraction of nipple in, 396 
 treatment of, 400 
 Sedatives, 88 
 Septicemia, 41 
 Sepsis, 41 
 Serre-n(vud, Koeberle's, 273 
 
 Tait's. 273 
 Serum therapy in septic endome- 
 tritis, 224 
 Sex, diagnosis of, 133 
 Sexual incompatability, 127 
 Shock, post-operative, 99 
 Silk sutures, 48 
 Silkworm gut, 49 
 Silver nitrate, 92 
 Simon's operation for vesico- vaginal 
 
 fistula, 188 
 Simpson's sound, 80 
 Sims' anterior colporrhaphy, 157 
 operation for vesico- vaginal fistu- 
 la, 186 
 Skene's endoscope, 83 
 glands, 32 
 
 hawk-bill scissors, 218 
 Speculum, Burrage's, 93 
 bivalve, 79 
 dack-bill, 79 
 Edebohl's, 217 
 Ferguson's, 78 
 vaginal, 78 
 Sponges, 62 
 
 Sponges, bleeching of, 52 
 gauze, 53 
 marine, 52 
 Staflfordshire knot, 352 
 Staphylococcus citreus, 41 
 epidermidis ulbus, 41 
 pyogenes albus, 41 
 pyogenes aureus, 42 
 Steriliziition, 43 
 of catgut, 49 
 of catgut chromicized, 51 
 of dressings, 51 
 by dry heat, 43 
 of field of o{)eration, 47 
 fractional, 44 
 of hands, 45 
 of instruments, 48 
 of irrigating fluids, 54 , '■■', ' 
 of kangaroo tendon, 51 
 Kronig's method of, for catgut, 
 
 49 ^ 
 
 by moist heat, 44 
 of normal salt solution, 54 
 of o{)erating trays, 48 
 of silk, 48 
 of silkworm gut, 49 
 of 8{)onges, 52 
 by steam, 44 
 of water, 54 
 Sterility, 125 
 ac(juired, 127 
 causes of, 127 
 congeniuil, 127 
 definition of, 127 
 treatment of, 128 
 Stenosis of cervix, 259 ^ 
 
 Stolti' method for anterior colpor- 
 rhaphy, 159 
 Streptococcus antitoxin in septic 
 
 endometritis, 224 
 Streptococcus pyogenes, 42 
 Stryhnine in amesthesia, 68 
 
 post-operative use of, 96 
 Subinvolution and sclerosis of 
 
 uterus, 235 
 Submucous fibroma of uterus 
 262 
 
 Subperitoneal fibroma of uterus. 
 
 262 
 Sutures in ca-liotomy, 272 
 
 buried, 273 
 
 in mass, 272 
 
 tier, 273 
 
 through and through, 272 
 
41() 
 
 INDEX. 
 
 T. 
 
 Tait'H opoiiitioii for vewco-vaj^iiml 
 fistiilii, ISH 
 
 |)orine()rrtiii|>liy, 165 
 
 Herre-iiii'iitl, 'iT-H 
 TiiiiHK)i>H, !t2 
 Taiiiiic acid, Stl, 14(i 
 Te(,'l)ni(|ue, gynucoloj^icuil, 40 
 Telaiigieotatii! inyoma, 'J()4 
 Therapeutics, gyiiiicological, 8(i 
 
 hygiene, general, 87 
 
 purgatives, 87 
 
 resolvents, 90 
 
 sedatives, 88 
 
 special gyna-cological drugs, 88 
 
 tonics, 88 
 Therapeutics, local, 90 
 
 applications to uterus, 92 
 
 counter-irritation, 91 
 
 curetting, 94 
 
 electric currents, 100 
 
 external applications, 90 
 
 internal applications, 90 
 
 intra-uterine injections, 93 
 
 {lelvic massage, 9() 
 
 vesical injections, 93 
 Tiierapeutics, post-operative, 96 
 Thiersch's solution, 54 
 Thirst, treatnient of, after cu'lio- 
 
 tomy, 97 
 Thomas' cup pessary, 246 
 Thrombus of broad ligament, 367 
 Tonics, 88 
 Toxaniiia, 41 
 Tracheitis, 224 
 Trachelorrhaphy, 216 
 
 indications for, 216 
 
 ligatures for, 217 
 
 nietiiods for operating, 217 
 
 needles for, 217 
 Trendelenberg position, 76 
 Tiiatigular ligament, 38 
 Tub; I pregnancy, 358 
 Tube, .;trophy of, 306 
 Tuberculo'^is, etiects on menstrua- 
 tion, iM8, 112 
 Tuberculosis, genital, 371 
 Tuberculosis of peritoneum, 377 
 
 diagnosis of, 379 
 
 treatment of, 380 
 
 symptoms of, 378 
 
 varieties of, 378 
 Tubes, inHanmiation of, 292 
 
 tuberculosis of, 373 
 
 Tubo-ovariaii abscess, 306 
 Tumors of breast, 388 
 
 of ovaiy, 330 
 
 (if uterus, 261, 276 
 
 of vagina, 182 
 
 of vulva, 139, 143 
 Tunica albuginea, 30 
 
 fibrosa, 30 
 
 propria, 30 
 Tui'pentine, 91 
 Tympanites after ojieration, 98 
 
 U. 
 
 Urachus, 14 
 Ureteral catheter, 85 
 
 searcher, 85 
 Ureteritis, 206 
 Uret-ero cystoscojjy, 190 
 Ureters, catheterization of, 85 
 
 diseases of, 206 
 
 relations of, 33 
 Urethra, anatomy of, 31 
 Urethra, atresia of, 194 
 
 causes of, 194 
 
 surgical treatment of, 195 
 
 symptoms of, 194 
 
 varieties of, 194 
 Urethra, dif'efises of, 141, 194 
 Urethra, granular erosion of, 198 
 
 appearance of urethra in, 198 
 
 treatment of, 198 
 Urethra, irritable, 196 
 
 causes of, 196 
 
 definition of, 196 
 
 treatment of, 196 
 Urethra, malformations of, 194 
 
 causes of, 194 
 Urethra, prolapse of, 142, 199 
 
 diagnosis of, 143 
 
 treatment of, 143 
 Urethra, stricture of, 198 
 
 causes of, 198 
 
 treatment of, 198 
 Urethrtd caruncle, 141, 199 
 
 situation of, 141 
 
 structure of, 141 
 
 8ym[)tom8 and appearance of, 142 
 
 treatment of, 142 
 Urethral dilator, 84 
 
 speculum and obturator, 84 
 Urethral venous angioma, 142, 199 
 
 diagnosis of, 142 
 Urethritis, 196 
 
 acute, 196 
 
INDEX. 
 
 417 
 
 UrefchritiH, chronic, l)»7 
 (lefitijtioii of, I'Hi 
 (liatfnoHiM of, 107 
 Konoriho'ul, I4r,, ISO, H)7 
 H.VtnptoniH of, 197 
 treiitiiiciit of, 1!»S 
 Urethiocclo, |j)il 
 
 (!oinpli(;iU.ioiis of, i!))» 
 foriimlioii of, l!><j 
 HyniptoinH of, IJ«> 
 treatment of, MM» 
 Urinary fintulic, IH4 
 Urinary oifranw, anatomy of, 31 
 Uro-geiiittil rej-ion, 88 
 Urogenital MinnK, 14 
 Uterine dreHHing fon;ei)8, 81 
 
 sound, 80 
 Utero-abdominnl pouch, 3;"> 
 UteruH, anatomy of, 21 
 Uterus, atresia of, accjuired, iJSO 
 Uterus, atresia of, congenital, 211 
 diagnosis of, 21 1 
 definition of, 21 1 
 sym|»toms produced by, 171, 172. 
 
 211 
 treatment of, 211 
 Uterus, applications to, 92 
 blood supply of., 27 
 cancer of, 276 
 Uterr cancer of body, 287 
 syi .ptoms and diagnosis of, 288 
 treatment of, 289 
 varieties of, 287 
 Uterus, cancer of cervix, 277 
 abdominal hysteiectomy for, 282 
 palliative treatment for, 28(5 
 pathology of, 277 
 radical treatment for, 281 
 symptoms of, 279 
 vaginal hysterectomy for, 282 
 Uterus, diseases of, 207 
 Uterus, displacements of, 241 
 anteflexion, 24,3 
 anteversion, 242 
 inversion, 257 
 latero-flexions, 25,3 
 laiero-versions, 2.'53 
 retroversion and retroflexioi. 246 
 Uterus, examination of, 81 
 Uterus, fibroid tumors of, 261 
 diagnosis of, 267 
 degenerations in, 265 
 etiology of, 265 
 hysterectomy for, 273 
 
 Uterus, fibroid tumors of, intor 
 stitial, 2(i2 
 intraligamentous, 2(i3 
 myomectomy for, 271 
 Dophoreitomy for, 270 
 polypoid, 262 
 structure of, 263 
 submucous, 2(i2 
 subjwritonoal, 262 
 Uterus, glandular polypus of, 261 
 Uterus, hypertrophy of, 240 
 Uterus, intlanunation of, 219 
 acute endometritis, 219 
 a<'ute metritis, 219 
 chronic corporeal endometritis. 
 
 229 
 chronic endocervicitis, 224 
 Uterus, injuries of, 213 
 Uterus, accidental puncture of, 213 
 
 treatment of, 213 
 Uterus, lacuration of cervix, 213 
 causes of, 213 
 digital examination in, 216 
 examination by speculum in, 216 
 o{)er:itive treatment for, 216 
 pathological changes in, 214 
 symptoms of, 215 
 varieties of, 213 
 Uterus, ligaments of, 24 
 Uterus, malformations of, 207 
 absence of, 208 
 bicornis, 209 
 causes of, 207 
 congenitally atrophic, 212 
 diagnosis of, 210 
 didelpliys, 210 
 frt'tal, 212 
 infantile, 212 
 septus, 210 
 subseptus, 210 
 unicornis, 209 
 Uterus, nerve su|)ply of, 27 
 neopiafmo of, 261 
 position of, 24 
 Uterus, sarcoma of, 289 
 diagnosis of, 291 
 diflusfc, 290 
 fibro-sarcoma, 289 
 sarcoma botryoiden, 290 
 symptoms of, 290 
 treatment of, 291 
 Uterus, sclerosis of, 2.35 
 stenosis of, 239 
 structure of, 23 
 
418 
 
 INDEX. 
 
 UteruM, nubinvolution of, 103, 235 
 
 HiipiKirtin^ npiMvratii8 of, 24 
 Uttiru8, tuboruuioHiH of, 372 
 
 V. 
 
 Vagina, anatomy of, 19 
 ^^agina, uppliRutionH to, 91 
 
 arreHt of developnioiit of, 174 
 V'agiiia, atresia and HteiioHi8 of, 173 
 
 <!au8e8 of, 174 
 
 complete and incomplete, 174 
 
 (lutinition of, 174 
 
 oHects of. 17r) 
 
 physical examination in, 17r> 
 
 surgical nietho<ls for relief of, 176 
 
 Hyirptoms of, 17«'» 
 
 treatment of, 175 
 Vagina, blotnl supply of, 21 
 Vagina, carcinoma of, I S3, 27S 
 
 pathology of, 1S3 
 
 symptoms and treatment of, 183 
 Vagina, cyats of, 182 
 
 diagnosiH of, 182 
 
 patTiology of, 182 
 
 treatment of, 1 82 
 Vagina, development of, 14, 174 
 
 diseaHes of, 171 
 
 double, 17.'» 
 
 tibroma of, 183 
 
 fornicet* of, 19 
 
 malformations of, 173 
 
 mucous ])olypi of. 183 
 
 neopla.sms of, 182 
 
 ocdu.sion of, 175 
 Vagina, prolapse of, 155 
 
 acute, 155 
 
 causes of, 15.5 
 
 chronic!, 155 
 
 methods of production of, 153, 
 155 
 
 treatment of, 156, 171 
 Vagina, structure of, 21 
 
 tuberculosis of, 372 
 Vaginal fixation of uterus, 262 
 Vaginal hysterectomy, 282 
 
 by clamps, 285 
 
 by ligatures, 283 
 Vaginal hyatero{)exy. 
 Vaginismus, 129 
 
 causes of, 129 
 
 definition of, 1. 
 
 treatment of, 12s» 
 Vaginitis, 177 
 
 acute, 177 
 
 Vaginitis, adhesive, 179 
 
 aphthous, 179 
 
 (jlironic!, 180 
 
 cystic, 179 
 
 definition of, 177 
 
 diagnosis of, 180 
 
 emphysematous, 179 
 
 etiology of, 178 
 
 gcmorrlKi-al, 145, 178, 180 
 
 granular, 179 
 
 pathology of, 178 
 
 primary, 177 
 
 secondary, 177, 179 
 
 simple, 178 
 
 symptoms of, 179 
 
 treatment of, 181 
 
 varieties of, 177 
 
 vesicular, 179 
 Varicose tumors of vulva, 141 
 VegeUitive cancer, 277 
 Ventral fixation of uterus, 2,53 
 Vesical calculus, 205 
 Vesico-hystero-cleisis, 189 
 Vestibule, 18 
 
 formation of, 15 
 Vestibulo-vaginul glands, 18 
 Viburninn pnmifolium, 89, 118 
 Vitelline membrane, 'M 
 VitelluH, 31 
 
 Vomiting, |K)8t-o|)erative, 100 
 Vulsellum, 81 
 Vulva, 17 
 
 development of, 15 
 
 diseases of, 132 
 Vulva, eruptive diseases of, 147 
 
 acne, 148 
 
 eczema, 147 
 
 erysiiielas, 148 
 
 erythema, 148 
 
 herjws progeni talis, 148 
 
 lichen, 147 
 
 prurigo, 147 
 Vulva, Tuematocele of, 1.35 
 
 hii'matoma of, 135 
 
 hernia of, 134 
 
 hydrocele of, 135 
 
 hy{)era'stlieaia of, 150 
 
 inrtammation of, 143 
 
 kraurosis of, 151 
 Vulva, malformations of, 132 
 
 absence of, 132 
 
 absence of labia in, 133 
 
 absence of clitoris in, 132 
 
 adherent prepuce in, 132 
 

 INDEX. 
 
 419 
 
 Vulvn, iimlfortniitioriH of, enisiwi- 
 fliafl, 132 
 hemaphrodiHrn, 1.S2 
 hyjHWfMMlias, i;J2 
 Vulva, plih^jrrnonous inflammation 
 of, 137 
 pruritus of, 148 
 pudendal lia-niatocelo, I3(J 
 pudendal lieniorrliago, !36 
 tuberculosis of, 371 
 Vi iva, tumors of, 1.39 
 condylomata, I3«> 
 <ilci)lmMti,isiM, 140 
 fibromata, 14(1 
 liponiata, 140 
 inyomatu, 140 
 myxomata, 140 
 neuromata, 141 
 papillomata, 13!) 
 r>rolapsuM uretlira-, 142 
 urethral earunele, 141 
 urethral venon.s ani'lonui, 142 
 Vulvitis. 143 
 clasHifioatii of, 143 
 diai,'nosis ol 14,') 
 diphtheritic, 144 
 follicidar, 144 
 
 \ ulvitis, gangrenous, 147 
 
 gonorrh<i"al, 145 
 
 {ihlogmonous, 144 
 
 purulent, 144 
 
 simple, 143 
 
 symptoms of, 144 
 
 trwitment of, 1 46 
 Vulvo-vaginal glands, 19 
 Vulvo- vaginal glands, abscess of, 
 
 cysts of, 1.38 
 
 W. 
 
 Water, warm, use of, 113, 118, 124 
 
 12.'5, 126 
 Water, sterile, 54 
 
 thera{)eutic effects of, 90, 91 
 Whites, 129 
 White line, .36 
 Wolffian body, 12 
 Wolffian ducts, 12 
 Wylie's dilator, 82 
 
 Z. 
 
 Zona pellupida, 30 
 Zinc chloride, 124 
 Zinc sulphatf;, 91