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 ■■■ -■- 
 
V, 
 
\ 
 
 DISEASES OF WOMEN. 
 
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 NUNQUAM ALIUD NATURA, ALIUD SAPIENTIA DIGIT. 
 
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DISEASES 
 
 OF 
 
 WOMEN 
 
 A TEXT-BOOK FOR STUDENTS AND PRACTITIONERS 
 
 '^ X 
 
 nv 
 
 j!' C^ WEBSTER, B.A., M.D. (Edin.), F.R.C.P.Ed. 
 
 DKMONSTRATOR OF ClYNECOLOGY, M'GILL UNIVERSITY; ASSISTANT GYNECOLOGIST, 
 
 ROYAL VICTORIA HOSPITAL, MONTREAL; FELLOW OF THE ROYAL SOCIETY OF 
 
 EDINBURGH; CORRESPONDING MEMBER OF THE ROYAL ACADEMY OF 
 
 MEDICINE OF PALERMO, ITALY, AND OF THE ITALIAN OBSTETRICAL 
 
 AND GYNECOLOGICAL SOCIETY; LATE SENIOR ASSISTANT TO 
 
 THE PROFESSOR OF MIDWIFERY AND DISEASES OF 
 
 WOMEN IN THE UNIVERSITY OF EDINBURGH 
 
 ILLUSTRATED .WITH 241 FIGURES 
 
 ^f! 
 
 \ 
 
 \ 
 
 MSDIOAL FACULTY J 
 
 EDINBURGH & LONDON 
 
 YOUNG J. PEN TL AND 
 
 MONTREAL: WM. DRYSDALE & CO. 
 
 1898 * 
 
V. 
 
 Edinburgh: printed for young j. pentland, ii teviot place, and 
 38 west smtthfiei.d, london, e.c., by morrison and gibb limited. 
 
 //■ 
 
 ■ I 
 
 - /y 'K 
 
 . J 
 
 \All R ights Reserved ] 
 
 ': { 
 
 t\ 
 
TO 
 
 WILLIAM GARDNER, M.D. 
 
 PROFESSOR OF GYNECOLOGY IN m'GILL UNIVERSITY 
 
 THIS BOOK IS DEDICATED 
 
 IN RECOGNITION OF HIS SPLENDID WORK IN 
 
 OPERATIVE GYNECOLOGY 
 
 AND AS A MARK OF SINCERE RESPECT 
 
 BY HIS COLLEAGUE 
 
 THE AUTHOR 
 
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PREFACE. 
 
 In preparing this volume I have endeavoured to keep 
 constantly before me the following aims, namely : — 
 
 1. To give prominence to the scientific basis of each 
 subject under consideration. For this purpose I have 
 given the most careful attention to modern researches in 
 sectional and dissectional anatomy, histology, embryology, 
 comparative anatomy, pathology, and bacteriology, in so 
 far as they bear on diseases of women, and have included 
 the chief facts gathered by myself in original investigations 
 carried on during the past nine years : 
 
 2. To study clinical features in their widest relationships, 
 endeavouring to give to them their proper proportional 
 values, and avoiding the faults of the school whose motto 
 is Michelet's dogma, Le bassin c'est la femme^ and whose 
 work has led to the opprobrious denunciation, prevalent 
 in so many quarters, of gynecological practice as a narrow 
 and debased specialism : 
 
 3. To insist upon caution in the adoption of therapeutic 
 measures not yet thoroughly tested, especially of many of 
 those which, in these latter days, have been hurriedly and 
 recklessly forced into publicity. 
 
 The illustrations have been chosen with special reference 
 to their teaching value, and have, for the most part, been 
 made from original drawings by myself. 
 
 ^ • J. C. WEBSTER. 
 
 M'GiLL University, Montreal, " 
 
 January 1898. 
 
f 
 
 v» 
 
 v 
 
 1 1 
 
 // 
 
 
 
 •■.'f':-,.-;-r; 
 
 <i ■ 
 
 , ,,♦■ 
 
CONTENTS. 
 
 CHAPTER I. 
 
 The Ovaries, 
 
 Form and size — Attachnieius — Position and relations — Naked-eye 
 appearance — Microscopic structure — Cortical zone — Medullary 
 zone — Development — Fonr.ation of corpus luteum — Physiological 
 note. The Fallopian tubes — Position and divisions — Structure — 
 Development — Physiological note — Comparative notes. Relics of 
 the mesonephros or Wolffian body, in the broad ligament — Organ 
 of RosenmUller — Other relics Page l 
 
 CHAPTER II. 
 
 The Uterus. 
 
 Shape — Component parts — Peritoneal covering — Muscular part of the 
 wall — Mucous membra .".e -Position — I'^nibryological explanation 
 of relationships — Normal movements — Special ligaments — De- 
 velopmeit — Notes on the Miillerian tracts in the vertcbrata. The 
 vagina — Shape — Structure — Physiological note — Development — 
 Changes after puberty. The hymen — Shape, structure, and 
 varieties — Infantile hymen — Comparative note — Development. 
 The External genitals — Mons veneris — Labia majora — Labia 
 minora — Clitoris — Vestibule — Corpus cavernosum urethrse — Bar- 
 tholinian" glands — Blood vessels — Lymphatics — Nerves. The 
 bladder — Shape and position — Structure. The urethra. The 
 ureters. Development of urinary tract and outer genitals. The 
 rectum i8 
 
V 
 
 xu 
 
 CONTENTS. 
 
 CHAPTER III. 
 The Pelvic Peritoneum. 
 
 \Vi 
 
 Relationships — Broad ligaments — Recto-vaginal pouch — Utero-vesical 
 pouch — Connective tissue of the pelvis — Divisions. The pelvic 
 floor — Meaning of the term — The floor studied by dissection — 
 Pelvic fascia — Superficial fascia — Pelvic muscles in floor — Viscera 
 and passages — Uterus — Floor studied by frozen sections — Physics 
 of floor Page 7 1 
 
 CHAPTER IV. 
 Puberty. 
 
 Systemic changes — Age of commencement — Prematurity — Delayed — 
 First onset of menstruation — Relation of puberty to nubility — 
 Disorders — Menstruation — General phenomena — Local pelvic \ 
 phenomena — Physical changes in pelvis — Type — Habit — Physio- ' 
 logical absence — Vicarious. The climacteric — General facts — 
 Structural changes in body — General phenomena — Relation to 
 special diseases — Early climacteric — Delayed climacteric. Dis- 
 turbances of menstruation — Amenorrhoea — Menorrhagia — Met- 
 rorrhagia — Dysmenorrhoea — Menstruation in relation to mental 
 irresponsibility in women ....... 100 
 
 ' CHAPTER V. 
 
 The Nervous System in Relation to Pelvic 
 
 Diseases. 
 
 General statements — Neurasthenia — Hysteria — Reflex neuroses in pelvic 
 diseases — Relation of pehiC diseases to insanity — Treatment of 
 pelvic pains in women , . . . , . .132 
 
 CHAPTER VI. 
 
 The Genital Tract in Relation to Micro- 
 organisms. V 
 
 Bacteriology of genital tract in normal conditions— In new-born child 
 — In girls and women — In menstrual periods — In pregnancy — 
 
 IN 
 
CONTENTS. 
 
 XIII 
 
 In the puerperium — Micro-organisms in the female urethra — 
 Relation of micro - organisms to pelvic diseases — Various fac- 
 tors concerned — Pathogenic organisms — Gonoccoci — Tubercle 
 bacillus Page 146 
 
 CHAPTER VII. ' 
 
 Case-Taking. 
 
 Anamnesis — Physical examination — General appearance and con- 
 figuration — Mammce — Abdomen — External genitals — Per vaginam 
 — Bimanual — Vaginal, rectal, and vesical inspection — Vaginal 
 specula — Volsella — Uterine sound — Dilators — Curette — As- 
 pirator .......... 160 
 
 CHAPTER VIII. 
 Minor Therapeutic Measures. '- 
 
 Vaginal douche — Vaginal plug — Vaginal medication — Uterine douche 
 — Uterine plug — Use of baths — Massage — Thermo-cautery — 
 Electro - cautery — Abdommal bandages — Pessaries — Use of 
 electricity .......... 216 
 
 CHAPTER IX. 
 
 Operative Measures in General. 
 
 Asepsis and antiseptics — General principles — Operator, assistants, and 
 nurses — Instruments, apparatus, swabs, ligatures, etc. — Cleansing 
 of patient — Cleansing of air and contents of room — Chemical 
 antiseptics — Apparatus, ligatures, instruments, etc. — Operating- 
 table— Operating-room — Needles— Sutures — Different forms of 
 sutures. Abdominal section in general — Preparation of patient — 
 Opening into peritoneum — Closure of wound — Dressing — Drainage 
 of peritoneum — After-treatment — Complications after operation — 
 Vag-nal section or colpotomy 244 
 
XIV 
 
 CONTENTS. 
 
 CHAPTER X. -' 
 
 Affections of Peritoneum and Cellular Tissue. 
 
 Peritonitis — General remarks — Etiology in general — Acute general — 
 Chronic general — Acute pelvic— Chronic pelvic — Tubercular — 
 Malignant. New growths in peritoneum — Pelvic cellulitis — 
 Differential diagnosis from pelvic peritonitis — Parametritis chronica 
 atrophicans— Circumscripta— Diffusa .... Page 298 
 
 CHAPTER XI. 
 Pelvic HiCMATocELE and Hematoma. 
 
 Hoematocele. Iltematonia. Other affections of pelvic connective 
 tissues — Cysts of broad ligaments — Solid tumours of broad li'^a- 
 ments- Solid tumours of round ligaments — R« troperitoneal 
 tumours in pelvis and lumbar regions — Tumours elsewhere than 
 in the broad and round ligaments — Hydrocele of round 
 ligament . 329 
 
 CHAPTER XII. 
 
 Affections of the Fallopian Tubes. 
 
 Anomalies of structure — Anomalies of position — Stricture and occlusion 
 — Inflammation — Varieties of salpingitis — Hydrosalpinx — Haemor- 
 rhage into the tubes — Haematosalpinx — Tuberculosis — Actinomy- 
 cosis — New growths 347 
 
 CHAPTER XIII. 
 Affections of the Ovaries. 
 
 Anomalies — Hernia — Prolapse — Inflammation — Tumours. Cystoma — 
 Simple — Proliferating multilocular — Papillomatous — Dermoid — 
 Parovarian cysts — Papillomatous cysts of broad ligament — CJhanges 
 in ovarian cysts — Ovarian hydrocele — Solid — Tuberculosis — 
 Coexistence of pregnancy and ovarian tumours — Minor conditions 
 in ovary . - 367 
 
 ' \ 
 
CONTENTS. 
 
 XV 
 
 CHAPTER XIV. 
 Affections of the Uterus. 
 
 Malformations — Imperfect development — Minor malformations — Inflam- 
 mation — Of the mucosa — Of the body — Acute endometritis — 
 Chronic endometritis — Of the whole uterine wall — Stenosis of 
 cervical canal — Atresia of cervix — Hypertrophy of cervix — Atrophy 
 of uterus — Laceration of cervix Page 409 
 
 CHAPTER XV. 
 
 Dr ^ACEMENTS OF THE UtERUS. 
 
 Anteversion — Anteflexion — Retroversion and retroflexion — Retroposi- 
 tion — Inversion 44;j 
 
 CHAPTER XVI. 
 
 FlBROMYOMA UtERI. 
 
 Varieties — Changes in tumour — Changes in uterus — Changes in other 
 organs — Tumours of the corpus uteri — Subperitoneal — Interstitial 
 — Submucous — Tumours of the cervix uteri — Intraligamentous — 
 Cystic tumours — Cystic fibromyoma — Cystic adenomyoma — Blood 
 cysts of wall 470 
 
 CHAPTER XVII. 
 Carcinoma Uteri. 
 
 Of the cervix — Of the corpus — Sarcoma uteri — Of the corpus— Of the 
 Cervix — Tuberculosis — Deciduoma malignum — Cystic distensions 
 of uterine cavity — Uterine polypi 505 
 
 CHAPTER XVIII. 
 Affections of the Vulva. 
 
 Malformations — Inflammation — CEdema and Gangrene — Eczema — 
 Herpes zoster — Lupus — Tuberculosis — Erysipelas — Varix — 
 Hematoma — Kraurosis vulvae — Pruritus vulvae — Elephantiasis 
 — New growths — Cysts — Venereal affections — Wounds — 
 Hernia 541 
 
XVI 
 
 CONTENTS. 
 
 CHAPTER XIX. 
 Injuries and Displacements of the Pelvic Floor. 
 
 Wounds of vulva and vagina — Rupture of perineum— Injuries to 
 fasciae and muscles— Downward displacement — Prolapsus uteri — 
 Cystocele — Rectocele Page 558 
 
 CHAPTER XX. 
 
 Affections of the Vagina and Hymen. 
 
 Vaginitis- -Relation to gonorrhoea — Vaginismus — Tumours — Tubercu- 
 losis — Stenosis and atresia — Septate vagina — Unilateral vagina 
 — Abnormal openings — Abnormalities of the structure of the 
 hymen .......... 581 
 
 CHAPTER XXI. 
 Affections of the Urethra and Bladder. 
 
 .Urethra — Developmental defects — Absence of the whole urethra — 
 Epispadias — Hypospadias — Dilatation — Stricture or stenosis — Dis- 
 placement — Urethritis — Urethrocele — Fissure — Angioma or 
 caruncle — Prolapse. Bladder — Malformations. Cyst — Displace- 
 ments — Tubercul' sis — Necrosis — Calculus — Neoplasms — Foreign 
 bodies — Rupture— \nomalies of ureter — Genito-urinary fistula. 
 Disorders of micturi I ^ ...... . 602 
 
 - // CHAPTER XXII. : 
 
 Certain Affections of the Rectum. 
 
 Rectocele — Prolapse — Fis.sure of anus — Haemorrhoids — Recto-vaginal 
 fistula — Gonorrhoea — New growths — Stricture — Pruritus — 
 Coccydynia 641 
 
 APPENDIX. 
 The Explanation of Menstruation. 
 
 \ 
 
 Relation to ovulation — Relation to Fallopian tubes — Relation to 
 
 sjjecial nervous mechanism — Relation to conception — Relation 
 
 I to body metabolism — Biological considerations — Relation to 
 
 rut 653 
 
 Index . . . 679 
 
LIST OF ILLUSTRATIONS. 
 
 FIG. 
 I. 
 
 •» 
 
 3- 
 
 4. 
 
 5. 
 6. 
 
 7. 
 8. 
 
 9. 
 10. 
 
 II. 
 12. 
 
 13- 
 14. 
 
 15. 
 16. 
 
 17. 
 18. 
 
 19- 
 20. 
 21. 
 22. 
 
 23. 
 24. 
 25. 
 26. 
 27. 
 28. 
 29. 
 30. 
 31. 
 
 Section through ovary . . 
 Ripe ovum .... 
 Developing ovary 
 
 i> >» . .' . 
 
 female pelvis from above (Nagel) 
 Ampulla of Fallopian tube . 
 Interstitial portion of Fallopian tube 
 Section through folds of tubal mucosa 
 Normal tube wall 
 
 Fallopian tube and ovary of a foetus 
 Adult tube and ovary 
 Different views of uterus . 
 Mucosa of corpus uteri of adult . 
 Section of mucosal gland in corpus uteri 
 Mucosa of cervix uteri 
 Vertical mesial section of pelvis of nullipara 
 Displacement of uterus by distended bladder 
 ,, ,, „ rectum 
 
 Foetal pelvis .... 
 External genitals of virgin . 
 Pacini-Vater nerve corpuscle 
 Genital nerve corpuscle 
 Internal genitals in new-born child (Nagel) 
 Dissection of pelvis from above ,, 
 
 Vessels of pelvis ■.■- -^'- ^ ^ 
 
 Arteries in broad ligament \" n- ,, 
 Pelvis of new-born child ,, 
 
 Arteries of uterus .... 
 Nerves of pelvic viscera (Krankenhauser) 
 Shape of contracted bladder 
 ReJati -n of ureters to cervix, vagina, and bladder 
 
 PAOB 
 
 5 
 5 
 7 
 8. 
 
 9 
 10 
 10 
 II 
 12 
 13 
 IS 
 19 
 21 
 22 
 
 25 
 27 
 30 
 
 30 
 
 32 
 
 41 
 
 43 
 
 45 
 48 
 
 49 
 51 
 52 
 53 
 55 
 57 
 58 
 62 
 
XVlll 
 
 LIST OF ILLUSTRATIONS. 
 
 PIG. 
 
 PAGE 
 
 32. Development of external genitals (Schroeder) . . '' 
 
 63 
 
 33* '• '♦ »» • • 
 
 63 
 
 34* f» »» »f • • 
 
 63 
 
 35* »» »» . »» ' • 
 
 63 
 
 3o» >> »» »f • • 
 
 63 
 
 37. Persistent Wolffian duct 
 
 66 
 
 38. Development of lower urogenital tract (Nagel) . 
 
 67 
 
 39« »» »» " »> • • 
 
 68 
 
 40* »» »» '» »» • • 
 
 68 
 
 41. Coronal section of pelvis 
 
 73 
 
 42. Dissection of front of pelvis (Savage) .... 
 
 . 76 
 
 43* »» " »5 • • • • 
 
 77 
 
 44. Parietal pelvic fascia ,, 
 
 . 78 
 
 45. Deep perineal fascia ,, . 
 
 79 
 
 46. Muscles of pelvic floor ,, 
 
 81 
 
 47* »> >» »!•••• 
 
 82 
 
 4°« »» f» ■ »»••••• 
 
 83 
 
 49. Deep dissection of perineum and vulvar regions (Savage) 
 
 84 
 
 50. Areas of abdomen . . . . . 
 
 174 
 
 51. Genu-pectoral position 
 
 182 
 
 52. Kelly's bladder speculum 
 
 186 
 
 53. Sims' speculum 
 
 190 
 
 54. Simon's set of spatular specula 
 
 192 
 
 55. Fergusson's speculum 
 
 193 
 
 56. Cusco's speculum 
 
 194 
 
 57. Volsella . 
 
 
 196 
 
 58. Bullet-forceps . 
 
 \ 
 
 197 
 
 59. Hegar's dilators 
 
 
 204 
 
 60. Hank's dilators . 
 
 
 205 
 
 61. Ellinger's dilator 
 
 
 206 
 
 62. Sims' dilator 
 
 
 207 
 
 63. Tents 
 
 
 208 
 
 64. Curettes . 
 
 
 212 
 
 65. Fritsch's double catheter 
 
 221 
 
 66. Budin's ,, 
 
 222 
 
 67. Hodge and Albert Smith pessaries .... 
 
 231 
 
 68. Thomas' pessary 
 
 232 
 
 69. Ring pessary 
 
 232 
 
 70. Zwanck's pessary 
 
 233 
 
 71. Schultze's pessary . 
 
 234 
 
 72. Thomas' pessary in position 
 
 236 
 
 73. Pedicle needle . 
 
 
 260 
 
LIST OF ILLUSTRATIONS. 
 
 XIX 
 
 74- 
 
 75- 
 76. 
 
 78. 
 
 79. 
 80. 
 
 81. 
 
 82. 
 
 83. 
 84. 
 
 85. 
 
 86. 
 
 87. 
 
 88. 
 
 89. 
 90. 
 
 91- 
 
 92, 
 
 93- 
 94. 
 
 95- 
 96. 
 
 97- 
 98. 
 
 99. 
 100. 
 
 lOI. 
 
 102. 
 T.03. 
 104. 
 105. 
 106. 
 107. 
 108. 
 109. 
 no. 
 III. 
 
 112. 
 
 113. 
 114. 
 
 US- 
 
 Martin's full-curved needles 
 Martin's needle-holder 
 Continuous catgut suture . 
 Ligatures applied to pedicle 
 Interlacing sutures . . < 
 Method of passing interlacing sutures 
 Glass drainage-tube . 
 Mikulicz's plug .... 
 Peritonitic adhesions in pelvis . 
 Inflammatory collection in broad ligament 
 
 ,, ,, behind pouch of Douglas 
 
 Chronic cellulitis in broad ligament 
 Hiematocele .... 
 
 Haematoma .... 
 Fallopian tube, with accessory ostium 
 Salpingitis .... 
 
 Pyosalpinx .... 
 Perisalpingitis .... 
 Pyosalpinx .... 
 Tubo-ovarian abscess . 
 Vaginal extirpation of uterus (Dunn) 
 
 Chronic ovaritis 
 
 Hydrops folliculoruni 
 
 Colloid ovarian cyst . 
 
 Ordinary multilocular ovarian cyst 
 
 Section of portion of ovarian cyst 
 
 Columnar cells lining wall of ovarian cyst 
 
 Papillomatous cyst of ovary 
 
 liojections on wall of papillomatous cyst 
 
 Dermoid cyst .... 
 
 >j »j • • • • 
 Parovarian cyst .... 
 
 »> >»•••• 
 
 Papillomatous cyst of broad ligament 
 Broad ligament cyst . 
 I-^rge ovarian cyst . . 
 Growth of ovarian cyst 
 Faecal accumulation in aboomen 
 
 PACK 
 
 261 
 262 
 265 
 
 266 
 
 267 
 267 
 
 268 
 
 269 
 
 315 
 323 
 323 
 324 
 
 337 
 337 
 338 
 343 
 348 
 348 
 349 
 349 
 350 
 352 
 358 
 
 359 
 360 
 
 370 
 373 
 374 
 374 
 375 
 375 
 376 
 
 377 
 378 
 379 
 381 
 382 
 
 383 
 384 
 38s 
 385 
 386 
 
XX 
 
 LIST OF ILLUSTRATIONS. 
 
 na 
 
 
 
 
 
 
 
 PAGE 
 
 ii6. 
 
 Splenic tumour . 389 
 
 117. 
 
 Liver enlargement .... 
 
 
 
 
 
 389 
 
 118. 
 
 f» >» 
 
 
 
 
 
 
 391 
 
 119. 
 
 Renal tumour . 
 
 
 
 
 
 
 392 
 
 laa 
 
 11 »» • « 
 
 
 
 
 
 
 393 
 
 121. 
 
 '» >> • 
 
 
 
 
 
 
 394 
 
 122. 
 
 Free ascitic fluid 
 
 
 
 
 
 
 394 
 
 123. 
 
 Ovarian hydrocele 
 
 
 
 
 
 
 396 
 
 124. 
 
 Superficial papilloma of ovary . 
 
 
 
 
 
 398 
 
 125. 
 
 Trocar 
 
 
 
 
 
 400 
 
 126. 
 
 Nekton's forceps . . *. . 
 
 
 
 
 
 402 
 
 127. 
 
 Rudimentary uterus . 
 
 
 
 
 
 409 
 
 128. 
 
 Uterus unicornis .... 
 
 
 
 
 
 409 
 
 129. 
 
 „ ,, with rudimentar 
 
 1 corn 
 
 u 
 
 
 
 410 
 
 130. 
 
 ,, didelphys 
 
 
 
 
 
 410 
 
 131. 
 
 ,, bicornis bicollis 
 
 
 
 
 
 411 
 
 132. 
 
 ,, ,, unicollis 
 
 
 
 
 
 4H 
 
 133. 
 
 ,, bicornis .... 
 
 
 
 
 
 412 
 
 134. 
 
 Septate uterus .... 
 
 
 
 
 
 412 
 
 135- 
 
 »> >>•••• 
 
 
 
 
 
 413 
 
 136. 
 
 Atresia of cervix 
 
 
 
 
 
 416 
 
 137. 
 
 Uterus incudiformis . 
 
 
 
 
 , . 
 
 416 
 
 138. 
 
 Nabothian follicle ... 
 
 
 
 
 
 420 
 
 139. 
 
 Multilocular polypus of cervix . 
 
 
 
 
 
 420 
 
 140. 
 
 Endocervicitis .... 
 
 
 
 
 
 421 
 
 141. 
 
 »> • • • 
 
 
 
 
 
 422 
 
 142. 
 
 Glandular endometritis 
 
 
 
 
 
 ■ 423 
 
 143- 
 
 Interstitial ,, . . 
 
 
 
 
 
 . 424 
 
 144. 
 
 Endometritis following abortion . 
 
 
 
 
 
 • 424 
 
 145- 
 
 Septic infection of uterine mucosa 
 
 
 
 
 
 . 426 
 
 146. 
 
 Schroeder's operation in endocervicitis 
 
 
 
 
 • 432 
 
 147. 
 
 Hypertrophic elongation of vaginal portion of cervix 
 
 
 . 437 
 
 148. 
 
 „ ,, supravaginal portion of cervix 
 
 . 437 
 
 149- 
 
 „ ,, intermediate ,, 
 
 . 438 
 
 150. 
 
 Martin's flap amputation of cervix 
 
 . . 
 
 • 439 
 
 151- 
 
 Appearance of cervix after amputation 
 
 
 
 • 439 
 
 152. 
 
 Circular amputation of cervix 
 
 
 
 . 440 
 
 153- 
 
 Emmet's operation in laceration of the cervix 
 
 
 
 • 443 
 
 154- 
 
 Metritis and anteversion .... 
 
 
 
 • 446 
 
 155- 
 
 Thomas' an teversion pessary i « . 
 
 
 . \ 
 
 • 446 
 
 156. 
 
 Pathological anteflexion of uterus 
 
 
 
 • 447 
 
 157- 
 
 Retroversion of uterus 
 
 . 
 
 . 
 
 
 
 . 450 
 
LIST OF ILLUSTRATIONS. 
 
 XXI 
 
 FIG. 
 
 PAGB 
 
 1 58. Retroflexion of uterus .... 
 
 
 
 ■ 450 
 
 159. ,, puerperal uterus . 
 
 
 
 ■ 451 
 
 x6o. Rotation of sound in replacing uterus . 
 
 
 
 • 457 
 
 161. Retroposition of uterus .... 
 
 
 
 . 463 
 
 162. Partial inversion of uterus .... 
 
 
 
 . 464 
 
 163. Complete inversion of uterus 
 
 
 
 ■ 465 
 
 164. Replacement of inverted uterus . • . 
 
 
 
 . 468 
 
 165. Section of fibromyoma .... 
 
 
 
 . 471 
 
 100. II II .... 
 
 
 
 . 471 
 
 167. Fibroid of anterior wall of uterus 
 
 
 
 . 474 
 
 168. Retroflexed uterus with fibroids . 
 
 
 
 . 474 
 
 169. Fibromyoma growing into broad ligament . 
 
 
 
 . 475 
 
 170. Fibroid polypus of uterus .... 
 
 
 
 . 475 
 
 171. Supravaginal hysterectomy 
 
 
 
 . 486 
 
 172. 11 II ... 
 
 
 
 . 487 
 
 ^73' >> »> ... 
 
 
 
 ■ 487 
 
 174. Koeberle's serre-nceud .... 
 
 
 
 • 489 
 
 175. Fixation of pedicle in extraperitoneal hysterectomy 
 
 
 . 490 
 
 176. Wolfler's treatment of pedicle in ,, ,, 
 
 
 • 492 
 
 177. A. R. Simpson's nail-curette . . . . 
 
 
 • 495 
 
 178. Morcellement 
 
 
 
 . 497 
 
 179. Cystic fibromyoma of uterus 
 
 
 
 . 500 
 
 180. Cystic adenomyoma (von Recklinghausen) . 
 
 
 
 . SOI 
 
 181. ,, ,, ..... 
 
 
 
 . 502 
 
 182. Large blood cyst of uterus . 
 
 
 
 ■ 503 
 
 183. Epithelioma of cervix uteri 
 
 
 
 506 
 
 184. Medullary carcinoma of cervix . 
 
 
 
 507 
 
 185. Carcinoma spreading in cervix . 
 
 
 
 507 
 
 186. Carcinoma cervicis 
 
 
 
 508 
 
 187. II II 
 
 
 
 508 
 
 •88. ,, ,, 
 
 
 
 508 
 
 189. Vaginal extirpation of uterus (Martin) 
 
 
 
 5'5 
 
 190. Grad ligature ...... 
 
 
 
 517 
 
 191. Vaginal extirpation of uterus (Pean) . 
 
 
 
 519 
 
 192. Carcinoma corporis uteri 
 
 
 
 522 
 
 193. 1. II 
 
 
 
 523 
 
 194. Curetting after incomplete abortion . 
 
 
 
 524 
 
 195. Large round-cell sarcoma of corpus uteri . 
 
 
 
 527 
 
 196. Spindle-cell sarcoma of corpus uteri . 
 
 
 
 527 
 
 197. Small round and oat-like cell sarcoma of corpus i 
 
 iteri . 
 
 
 528 
 
 198. Tubercular endometritis 
 
 
 
 529 
 
 199. Sarcoma of corpus uteri 
 
 
 
 531 
 
xxu 
 
 LIST OF ILLUSTRATIONS. 
 
 
 FIO. . 
 
 
 
 
 
 PACE 
 
 200. Deciduoma malignum 
 
 
 . 533 
 
 20I. Villus-like mass in deciduoma malignum . . . 
 
 . 535 
 
 202. Mucous polypus 
 
 t • • 1 
 
 . 537 
 
 203. Placental and fibrinous polypus 
 
 
 . 539 
 
 204. Schroeder's diagram illustrating 
 
 malformation of vulva 
 
 . 542 
 
 205. ,, „ 
 
 »» »» • 
 
 . 542 
 
 206. ,, „ 
 
 »> 1* « 
 
 . 542 
 
 207. 
 
 )> >i < 
 
 . 542 
 
 208. 
 
 >f >» • 
 
 . 542 
 
 209. Fibrosis of Krause's genital corpuscle . . . . 
 
 • 551 
 
 210. ,, Meissner's ,, 
 
 • 
 
 
 
 • 551 
 
 211. ,, nerve in clitoris 
 
 . 
 
 
 
 • 552 
 
 212. Complete rupture of perineum 
 
 • 
 
 
 
 . 559 
 
 213. Repair of incomplete rupture of 
 
 perineum 
 
 
 
 . 560 
 
 214. » 
 
 >» 
 
 
 
 . 561 
 
 215- » 
 
 II 
 
 
 
 . 562 
 
 216. 
 
 II 
 
 
 
 . 562 
 
 217. Repair of complete ,, 
 
 11 
 
 
 
 • 563 
 
 218. 
 
 II 
 
 
 
 . 564 
 
 219. Prolapsus uteri . 
 
 
 
 
 . 573 
 
 220. „ „ . . . 
 
 
 
 
 
 . 573 
 
 221. „ „ . . . 
 
 
 1 
 
 
 
 • 574 
 
 222. Cystocele .... 
 
 
 
 
 
 . 575 
 
 223. Rectocele 
 
 
 
 
 
 . 576 
 
 224. Anterior colporrhaphy 
 
 
 
 
 
 . 578 
 
 225. Colpoperineorrhaphy . 
 
 
 
 
 
 • 579 
 
 226. Atresia of vagina 
 
 
 
 
 
 • 591 
 
 227. Hymeneal atresia 
 
 
 
 
 
 • 591 
 
 228. Atresia of vagina 
 
 
 
 
 
 • 592 
 
 229. „ half of vagina 
 
 
 
 
 
 • 592 
 
 230. Vaginal tube 
 
 
 
 
 
 • 597 
 
 231. Gonorrhoeal pus from urethra 
 
 
 
 
 
 . 604 
 
 232. Urethral wall in gonorrhoea 
 
 
 
 
 
 . 604 
 
 233. Urethral caruncle 
 
 
 
 
 
 . 605 
 
 234. Vesico-v^inal fistula knives 
 
 
 
 
 
 . 623 
 
 235. Sims' and Simon's operation for 
 
 vesico-vaginal fistula 
 
 . 624 
 
 236. Operation for very small 
 
 »> »» 
 
 . 626 
 
 237. ,, medium 
 
 »i r» 
 
 . 627 
 
 238. „ large ' 
 
 i> ^ II 
 
 . 629 
 
 239. Bishop's operation for \: ' 
 
 >) »i 
 
 . V 631 
 
 240. Kolpokleisis 
 
 ■ . . • 
 
 . . 633 
 
 241. Pozzi's operation for uretero-vagi 
 
 nal fi 
 
 stula 
 
 
 ■ 
 
 . . 635 
 
 A 
 
DISEASES OF WOMEN. 
 
 - u 
 
 II 
 
 )• 
 
\?i 
 
 u 
 
 // 
 
 u 
 
 r J 
 
 u 
 
 n 
 
 > ( 
 
DISEASES OF WOMEN. 
 
 — -♦- 
 
 CHAPTER I. 
 
 • THE OVARIES. 
 
 The ovaries, two in number, lie in the pelvis, one behind 
 each broad ligament. 
 
 Form and size. — Each is a somewhat flattened body, 
 with the following measurements : — 
 
 Length 
 
 Breadth 
 
 Thickness 
 
 I to 2" in. (2.5 to 5 cm.). 
 S .. 4 ,y (i-S M 3 cm.), 
 i M i „ (0.6 „ 1.3 cm.). 
 
 It is thus evident that the size varies considerably. The 
 right ovary is usually larger than the left. 
 
 In describing the organ one can recognise two surfaces, 
 a free border, an attached border, and two extremities. 
 
 One surface looks upwards and inwards, the other down- 
 wards and outwards. The free border is rounded, convex, 
 and looks backwards and inwards. The border attached to 
 the broad ligament is straight. The upper and outer or 
 tubal extremity is directed towards the pavilion of the tube, 
 the lower and, inner or uterine extremity pointing towards 
 the uterus. 
 
 Attachments. — The ovary is kept in place by the follow- 
 ing structures : — 
 
 I. T^c broad ligament. — The posterior layer of this 
 
:/ 
 
 \i 
 
 2 THE OVARIES. 
 
 ligament, to which the border of the ovary is attached, is 
 generally somewhat raised as a kind of fold, and by some is 
 called the mesovarium. 
 
 2. The suspensory ligametit. - This is merely the upper 
 free border of the outer part of the broad ligament — the 
 infundibulo-pelvic portion, which runs from the ovary 
 upwards, outwards, and backwards to the psoas muscle. It 
 is made up of connective tissue and a few smooth muscular 
 fibres. The ovarian vessels run in it. 
 
 3. The ovarian ligament. — This is a band in the posterior 
 layer of the broad ligament, which extends from the uterine 
 end of the ovary to the upper part of the uterus, where it is 
 attached between the round ligament and Fallopian tube. 
 It is about li in. (3 cm.) in length. 
 
 4. The ovarian fimbria. — One of the larger fimbriae of 
 the lower portion of the pavilion of the tube extends down- 
 wards and inwards along the broad ligament towards the 
 tubal end of the ovary. In some cases it is directly 
 attached to the latter, but in other cases it is not. 
 
 Position and relations. — The organ is attached to the 
 upper part of the posterior layer of the broad ligament a 
 short distance below the Fallopian tube. It is situated at 
 the level of the brim, and near the lateral wall of the pelvis. 
 From the tubal extremity the long axis runs downwards 
 and inwards, crossing the plane of the pelvic inlet obliquely. 
 The ovaries may not have the same relative positions on both 
 sides, on account of variations in the position of the uterus. 
 Thu3, when that organ is nearer one side of the pelvis, the 
 long axis of the ovary of that side crosses the pelvic brim 
 more vertically than does that of the other ovary. The 
 ovaries have a range of movement, varying according to 
 the mobility of their ligaments. They are also affected in 
 position by movements of the uterus, by varying degrees of 
 distension of bladder, small intestine, caecum, and rectum. 
 
 Naked -eye appearance — The outer surface is pale, 
 and with a lustre somewhat resembling that of a mucous 
 
 h 
 
 f 
 
 h 
 
MICROSCOPIC STRUCTURE. 3 
 
 surface, and has not the smooth glistening aspect of 
 a surface covered with peritoneum. It presents various 
 rounded projections of varied sizes,— caused by the under- 
 lying Graafian follicles in different stages of development, — 
 the largest of which may measure from | to ^ in. (i to 2 
 cm.) in diameter. Furrows of different shapes and sizes 
 are seen on the surface, and also puckered scars, due to 
 the rupture of old Graafian follicles. 
 
 The ovary feels something like the testicle, but it is 
 not so firm, being richer in lymphatics. When a section 
 is made into it, clear fluid escapes. (This must not be 
 described as an oedema.) 
 
 At the junction of the ovary and broad ligament a 
 slightly raised white line of tissue is seen — " the white 
 line of Farre " (or of Waldeyer). It marks the junction of 
 the peritoneum and the germ epithelium covering the ovary. 
 
 Microscopic structure. — The surface of the ovary, as far 
 as the white line, is covered with low cubical epithelium. 
 The nearer the period of puberty the higher are the cells 
 of this layer. In advanced years they become considerably 
 flattened, and tend to disappear. 
 
 The substance of the ovary is made up of two portions : — 
 
 I. Cortical or Parenchymatous Zone. 
 
 This consists of a dense network of connective tissue, in 
 the midst of which Graafian follicles of various degrees of 
 development are found. It is more compactly arranged in 
 the outer part. Elastic fibres are also found. According 
 to Nagel there are no smooth muscular fibres in it. 
 
 In this layer are found three varieties of Graafian follicle, 
 namely, primary, growing, and ripe. 
 
 The primary follicles are too small to be seen with 
 the naked eye. In the adult they are found near the 
 surface as an irregular double row, the individual follicles 
 being considerably separated from one another. Each 
 
THE OVARIES. 
 
 consists of a covering of low epithelial cells, derived 
 from the original germ epithelium, which surrounds the 
 primordial ovum. The latter is a rounded cell with a 
 single nucleus ; very rarely with tw6 nuclei. Nagel 
 measured the ovaries fresh in salt solution, and found their 
 diameters to vary from 48 by 54 /u, to 64 by 69 /x. 
 
 The nucleus (germinal vesicle), situated in the centre 
 of the ovum, measured from 29 to 32 /u,; Trinchese and 
 others have described around it a membrane with a double 
 outline. There is a nucleolus (germinal spot) centrally or 
 peripherally placed, as well as one or more paranucleoli. 
 
 The groiving follicle. — These are found in the lower 
 portion of the cortical layer. The first sign of growth in 
 the primary follicle is that the epithelial cells surrounding 
 the ovum increase in size and number, forming a mass 
 of several layers — stratum granulosum. In this vacuolation 
 occurs, in which gradually accumulates the liquor folliculi, 
 formed partly by transudation from the surrounding tissues, 
 partly by breaking down of cells of the stratum granulosum. 
 Those cells which do not break down remain as a kind 
 of stalk {discus proligerus^ cumulus oophorus)., in which the 
 ovum is embedded. 
 
 While these changes are taking place in the stratum 
 granulosum the surrounding connective tissue elements are 
 being arranged concentrically, to form an outer covering of the 
 follicle — the theca folliculi. This consists of two portions, 
 the tunica externa or fibrosa and the tunica interna or 
 propria. The latter is more cellular than the former, and 
 is rich in capillaries. Between the theca and the stratum 
 granulosum is a thin structureless membrane, produced by 
 the epithelial cells, according to Waldeyer. 
 
 About the time of the appearance of this so-called base- 
 ment membrane the thin structureless zona pellucida is 
 formed around the ovum from the epithelial cells. Accord- 
 ing to Nagel a very thin space, the perivitelline space, 
 exists between it and the ovum. Next appears in the 
 
THE OVUM, 
 
 centre of the protoplasm of the ovum the yolk particles 
 (deutoplasma). As it increases, the germinal vesicle is 
 pushed more towards the peri- 
 phery. The vesicle is never found 
 surrounded by the yolk particles, 
 and when the ovum is nearly filled 
 with these particles there still re- 
 mains a thin covering of unaltered 
 protoplasm around the vesicle. 
 
 The ripe follicle. — This is a more 
 '^'- less rounded structure, in which 
 .J following parts can be dis- fig. i.-Section through ovary 
 
 tmguished : — of •'^ young woman. Several 
 
 I. The ovum.— (Sometimes two P"niary follicles and a nearly 
 
 . ripe one are shown. 
 
 or more ova are seen.) 
 
 This is made up of the following : — 
 Clear protoplasm. — This is found as a peripheral layer, 
 and as a thin layer surrounding the germinal vesicle. 
 
 Yolk protoplasm. — This fills the 
 greater part of the ovum, and is 
 made up of coarse and fine par- 
 ticles with strong refractile powers. 
 Germi?ial vesicle {nucleus). — This 
 body is rounded, its border having 
 a double contour. 
 
 Germinal spot {nucleolus). — This 
 has a somewhat yellowish appearance, 
 and is capable of amoeboid move- 
 ments. After death it breaks up into 
 several parts. 
 
 Paranucleolus. — One or more can 
 be seen. They appear to be thick- 
 few of the surrounding enings in the protoplasmic reticulum 
 
 epithelial cells. of the nucleus. 
 
 2. The perivitelline space. 
 
 3. Zona pellucida. — This has a radial striation. 
 
 
 2. Ripe ovum, with a 
 
6 THE OVARIES. 
 
 4. The epithelial cells surrounding the zona pellucida. 
 — There are several layers of these, the inner iwo or three 
 having their long axes arranged radially to the ovum. The 
 inner row in particular has a longitudinally striated appear- 
 ance, called by Bischoff the corona radiata. These stria- 
 tions appear to be continuous with those of the zona 
 pellucida. 
 
 The outer cells are more rounded. They possess a finely 
 granular protoplasm. The stalk of the discus proligerus is 
 composed of cells very like those in the stratum granulosum. 
 
 5. Stratum granulosum. — This consists of two or more 
 layers of low cylindrical cells, forming the inner wall of the 
 follicle. 
 
 6. Liquor folliculi. — This is a clear, slightly yellow, glairy 
 fluid, rich in par-albumin. 
 
 7. Theca folliculi. — The inner layer is made up of more 
 numerous cells than at an earlier period. As the follicle 
 approaches ripeness, there appear in these cells shining 
 yellow particles. These are known, after the escape of the 
 ovum, as the lutein cells of the corpus luteum. 
 
 II. Medullary or Vascular Layer. 
 
 This forms the central portion of the ovary, and is con- 
 tinuous with the broad ligament through the hilus. It 
 consists of a connective tissue stroma, smooth muscle fibres, 
 and is very rich in blood vessels. There is a well-marked 
 plexus of arteries and veins in the hilus. Lymphatics exist 
 and form networks around the Graafian follicles. The 
 nerves seem to end largely in the vessel walls, but special 
 plexuses are found around the follicles, from which delicate 
 branches penetrate as far as the stratum granulosum. 
 
 Development. — The ovary is developed from epiblast and meso- 
 blast on the inner surface of the Wolffian body. The epiblast, a 
 specialised portion of the coelomic lining, very early forms a mass 
 consisting of several layers of cells, the germinal epithelium. In the 
 
THE VASCULAR LA YER. 
 
 deepest portions certain of these cells increase in size and give rise to 
 the primordial ova. 
 
 As this layer increases in thickness, processes of the underlying 
 mesoblast of the Wolffian body extend outwards among the germinal 
 cells, forming a network-like stroma, in the meshes of which lie 
 primordial ova, surrounded by germ cells. 
 
 The manner in which the Graafian follicles develop I have 
 already described. As the ovary grows, it becomes raised from the 
 surface until it is attached only by a narrow 
 hilus. 
 
 The surface remains covered with germinal 
 cells. Extending inwards from this layer may 
 be seen, occasionally, columns of similar cells, 
 which have not been cut off by the stroma. 
 
 In foetal life, and in the first period after 
 birth, the majority of primordial ova and primary 
 follicles disappear. Throughout sexual life this 
 diminution continues, the stroma becoming more ^iq 
 prominent as age advances. The development 
 of the primary into the Graafian follicles begins 
 l)efore puberty, as a rule, though it may take 
 place in foetal life or in childhood. These early 
 ripened ova have the same appearances as those 
 found in the adult, but they never reach more than half the size. 
 
 The opening of the ripe follicle is a process which occurs indepen- 
 dent of menstruation. It is now believed not to be due to increase of 
 intrafollicular pressure, but to a great increase in the thickness of the 
 inner layer of the theca folliculi, owing to the swelling of its cells with 
 yellow particles (lutein cells), and to its becoming arranged in a wavy 
 manner (Nagel). Into the portions which project inwards many vessels 
 extend. Owing to this pressure from without, the contents of the 
 follicle are forced in the direction of least resistance, namely, outwards, 
 thus breaking the thin projecting covering of the follicle known as the 
 stigma. 
 
 Pari passu with the development of the lutein cells, there is a fatty 
 degeneration in the cells of the stratum granulosum, and in those of 
 the discus proligerus. This enables the ovum to break loose from 
 its covering cells. 
 
 Formation of corpus luteum. — After the ovum escapes, the 
 follicle, containing degenerating epithelial cells, is filled with a blood 
 effusion. The opening of the follicle closes, and the wavy yellow band 
 of lutein cells presses further inwards. The blood gradually becomes 
 absorbed, so that the space in the centre of the follicle is almost entirely 
 
 3. — Section 
 through developing 
 ovary. The germi- 
 nal epithelium and 
 primordial ova are 
 shown. 
 
8 
 
 THE OVARIES. 
 
 Fig. 4. — Section 
 through developing 
 ovary. The primary 
 follicles are shown. 
 
 obliterated, being occupied by the yellow band. Then the lutein cells 
 begin to disappear, so that the yellow colour is gradually lost, and in 
 
 place of the yellow body is found a clear 
 colloid mass, the corpus albicans, in the 
 centre of which a few blood crystals may 
 be found. This gradually diminishes in 
 size. 
 
 The terms " true corpus luteum " and 
 "false corpus luteum " should be abandoned. 
 The former is applied to the condition found 
 when pregnancy occurs, the latter referring 
 to that found in the non-pregnant state. 
 There is no difference between them save as 
 regards duration. 
 
 When pregnancy follows on ovulation, the 
 corpus luteum takes several months to become 
 reduced. When pregnancy does not occur, this happens in a few weeks. 
 According to Nagel, the corpus luteum acts as a kind of splint, steady- 
 ing the ovary while repair takes place. 
 
 Besides the well-formed follicles which rupture, many seem to break 
 down in the normal ovary. The ovum and surrounding epithelium 
 degenerate and get absorbed along with the liquor folliculi. In these 
 conditions leucocytes have been seen to penetrate to the ovum. Also, 
 the epithelial cells surrounding it have been noticed to penetrate the 
 zona pellucida, and to enter it. 
 
 Notwithstanding these changes in the ovary during sexual life, the 
 size of the organ remains pretty constant. Towards the menopause it 
 diminishes. 
 
 After the menopause it is hard, shrunken, and irregular ; the cover- 
 ing epithelium becomes flattened, and largely disappears. The Graafian 
 follicles are wanting. The connective tissue stroma is dense and hard, 
 especially at the periphery (at this time often called the "tunica 
 albuginea "). 
 
 Physiologfical note. — The ovary is the most distinctive possession 
 of the female sex. According to Nagel, it is the only part of the female 
 genitals which may never be found with the testes in hermaphroditism. 
 True essential hermaphroditism, in which both testes and ovaries are 
 present, probably cannot exist. According to Nagel, this is because of the 
 very early changes in the germinal epithelium, whereby the maleness or 
 femaleness of the sex is first of all laid down. The rest of the genital 
 apparatus is a later formation, and it is not surprising that hermaphro- 
 ditism might occur in it. The relation of ovulation to menstruation 
 and to the sexual characters is discussed in the Appendix. 
 
 !\ 
 
THE FALLOPIAN TUBES. 9 
 
 The influence of the ovaries on metabolism is not well known. It is 
 l)elieved that some secretive product is introduced into the system by 
 ihem, which can influence metabolism. Their removal is attended with 
 various changes {vide pp. 654, 668). 
 
 THE FALLOPIAN TUBES. 
 
 The Fallopian tubes lie in the upper free margin of the 
 broad ligaments, being joined to the uterus, one on each 
 
 / 
 
 Fig. 5. — Female pelvis seen from above. — From Nagel. 
 
 6. Rectum. 
 
 7. Infundibulo-p)elvic ligament. 
 
 1. Bladder. 
 
 2. Uterus. 
 
 3. Round ligament. 
 
 4. Fallopian tube. 
 
 5. Ovary. 
 
 I 
 
 8. Ovarian ligament. 
 
 9. Broad ligament. 
 
 f ■ 
 
 62 
 
 to 5 in. 
 
 side, at the corner. Ordinarily they are from 
 (6 to 12.8 cm.) in length, and are often unequal. 
 
 The direction of the tube, when the uterus is anteverted, 
 is from the uterine cornu upwards, outwards, and forwards, 
 for a short distance ; then upwards, outwards, and back- 
 wards ; then downwards, backwards, and slightly inwards. 
 In this way a curve is formed. 
 
 The inner part of the tube varies in position with move- 
 
lO 
 
 THE FALLOPIAN TUBES. 
 
 merits of the uterus. The ampulla is capable of moving 
 also, owing to the mobility of that part of the broad liga- 
 ment to which it is attached. 
 The fimbriated end is also 
 freely movable. 
 
 The tube may be de- 
 scribed in three divisions — 
 I. Isthmus. — This is the 
 innermost portion which 
 runs through the uterine 
 wall, to communicate with 
 the funnel-shaped depres- 
 sion of the uterine cavity at 
 
 the cornu. It admits only a 
 Fig. 6 -Transverse section through ^^^ ^^ ^^^ enlarges gra- 
 ampulla of Fallopian tube of adult. , ,, /. . , . i 
 
 dually from withm outwards. 
 
 2. Ampulla. — This forms two-thirds of the tube, and 
 extends from the isthmus to the pavilion. Its lumen is 
 larger than in the rest of the tube ; it admits a uterine 
 sound, and increases in diameter from within outwards. 
 Usually one or more curves 
 
 exist in this part, remains of 
 the spiral convolutions found 
 in the foetus. There is a slight 
 constriction where the ampulla 
 passes into the pavilion. 
 
 3. Pavilion, infundibulum, 
 or fimbriated extremity. — 
 This is the outer funnel-shaped 
 end of the tube, which is 
 marked by a number of fim- 
 briae. A slight constriction of 
 the wall marks its inner limit, 
 but there is no muscular 
 thickening worthy the name of sphincter. The ostium 
 varies from 2 to 5 mm. in diameter, and is surrounded by 
 
 Fig. 7. — Section through inter- 
 stitial portion of Fallopian 
 tube. 
 
 l^ 
 
 l\ 
 
STRUCTUKE, 
 
 II 
 
 fimbriae. I^allantyne and Williarrs divide these into the 
 major (musculo-mucous) and minor (mucous). The former 
 number from three to five, the latter being placed between 
 them. ! 
 
 One of the former runs from the lower part of the tube 
 along the free border of the broad ligament towards the 
 
 Fig. 8. — Section through folds of tubal mucosa. 
 
 / 
 
 ovary, to which it may or may not be attached. It is 
 known as the ovarian fimbria, and is generally grooved on 
 its mucous surface by a longitudinal furrow. 
 
 Structure.— It is usual to describe the tube as having a 
 peritoneal, a muscular, and a mucous layer. 
 
 1. Peritoneal covering. — This covers the ampulla, save 
 on the lower surface. It is in reality the junction of the 
 anterior and posterior layers of the broad ligament, and is, 
 for the most part, loosely connected with the muscular part 
 of the tube. Close to the uterus it is more firmly attached. 
 Between the two run vessels and nerves. (Remains of the 
 primitive kidney are sometimes found here.) The large 
 fimbriae are covered on their outer surface and on their 
 outer ends with peritoneum, the minor fimbriae being 
 usually entirely covered with mucous membrane. 
 
 2. Muscular portion. — This is composed of two layers of 
 smooth muscular fibres, an outer longitudinal and an inner 
 
la 
 
 THE FALLOPIAN TUBES. 
 
 circular. It is thickest near the uterus, and thins out 
 towards the outer end. Both are of about the same thick- 
 ness in the ampulla. At the 
 isthmus the circular layer is most 
 marked. Several observers have 
 described a few longitudinal fibres 
 internal to the circular layer. 
 ( These are well-marked in the 
 cow.) 
 
 3. Mucosa. — This increases in 
 thickness and complexity from 
 the uterine end outwards towards 
 the pavilion. In the isthmus it 
 is found in its simplest form, 
 there being no fringes. The 
 transverse section of the lumen 
 appearance. There is a small 
 tissue of close texture. It is 
 
 Frc. 9. — A small piece of nor- 
 mal tube wall, taken from a 
 portion in which the mucosa 
 is not raised in folds. The 
 columnar ciliated epithelium 
 is separated from the muscu- 
 lar part of the wall by a very 
 small quantity of connective 
 tissue. 
 
 has a somewhat stellate 
 
 amount of submucous 
 
 covered with columnar ciliated epithelium. 
 
 In the ampulla the mucosa is arranged in a series of 
 longitudinal folds. These increase in number and size 
 from the uterine end outwards. On transverse section they 
 appear as a number of delicately branched processes, which 
 occupy the entire lumen. These are covered with columnar 
 ciliated epithelium. Under this is a delicate connective 
 tissue, consisting of branching and round cells, vessels, and 
 nerves. The amount of this submucous tissue resting on 
 the muscular part of the wall is very small. No glands 
 exist normally in the tube. Occasionally, the mucosa of 
 the ampulla shows variations from this normal arrangement. 
 It may in parts resemble that of the isthmus, even that of 
 the corpus uteri containing glands ; or there may only be 
 a much less complex arrangement of the folds. \ 
 
 Development. — The Fallopian tubes are developed from the ducts 
 of Muller. These structures arise as follows : — In very early life 
 (observed by Nagel in an embryo ^ in. (7 mm.) in length), the coelomic 
 
 I- 
 
 » \ 
 
DE VELOPMENT, 
 
 »3 
 
 epithelium on the surface of the WolflTian bo<ly forms more than one 
 layer, from the deepest of wnich MUller's duct forms in close proximity 
 to the Wolffian duct, which is more deeply placed. In an embryo \ in. 
 (12 mm.) in length Nagel found that the MUllerian duct was a short 
 funnel-shaped tube open at its upper end. It was lined with columnar 
 epithelium save at the distal end, where it was cubical. Thereafter the 
 duct extended gradually along the ventral aspect of the Wolffian body, 
 until it approached the urogenital sinus. At first they are connected 
 with the coelomic epithelium, Int later they are cut off from it 
 entirely save at the upf>er end, being embedded in mesodermal tissue. 
 This stage has been found by Nagel in an embryo i in. (2,5 cm.) in 
 length. 
 
 By means of a rotation inwards of the lower end of the Wolffian body, 
 the Miillerian duct, which at first lay external to the Wolffian, is made 
 in its lower part to lie internal. The lower ends of the two ducts are 
 now closely applied. Their inner walls afterwards coalesce to form a 
 single duct (the uterus). From the upper unblended portions the tubes 
 are derived. The bend made in the ducts, owing to the inward rota- 
 tion of the Wolffian bodies, marks the lower limit of the tubes, for 
 here develop the round ligaments from mesodermal strands, leading to 
 the anterior abdominal wall. 
 
 Around the primitive epit^-elial tubes the mesoderm has been arrang- 
 ing itself in a circular manner. This afterwards forms the muscular and 
 connective tissue elements of the tube 
 walls. These can be made out distinctly 
 by the fifth month. The upper end of 
 the tube is at first a well-marked, 
 rounded projection. Early it shows 
 shallow notches. By the fourth month 
 small fimbrise can be seen. At full 
 time the epithelium lining the tube has 
 cilia. 
 
 The folds in the mucosa begin in the ampulla about the fifth month. 
 They are well-marked at full time. 
 
 The MuUerian duct possesses a half-spiral turn inwards, as already 
 stated. After the fourth month several folds may usually be noted in 
 the ampullary portion of the tubes. 
 
 Physiological note. — The tube serves to convey the ovum to the 
 uterus. The fimbriae offer a large number of ways by which it may Ije 
 led into the tube, though the fimbriated end plays but a passive part, so 
 far as is known. There is no proof that it grasps the ovary while the 
 ovum is being shed. It is well known, from experiments, that particles 
 placed in the pelvic peritoneum are attracted to the tube by currents set 
 
 Fig. 10. — P'allopian tube and 
 ovary of a fcetus. 
 
m 
 
 I 
 
 >4 
 
 77/E FALLOPIAN TUBES. 
 
 up in the thin layer of serum on the peritoneal surface by the action of 
 the cilia lining the fimbria;. 
 
 Probably many ova never reach the tulxis, but are broken up in the 
 peritoneal cavity. 
 
 After the menopause the tulies get thinner, the muscle atfophies, the 
 connective tissues become dense, the nuicosal folds gradually disap[)ear 
 towards the inner part of the tul)e, the epithelium is more or less cast 
 oflf, and may form a plug in the lumen. 
 
 Comparative notes. — In several fishes there are no Fallopian 
 tubes. The ova escape into the jK>ritoneal cavity and afterwards to the 
 exterior. In some varieties this takes place even where there are tulx;s. 
 In the cartilaginous fishes tul)e and ovary are in close union ; in some 
 the ovary is covered with a firm capsule, through which the eggs must 
 burst. In Ixjny fishes this capsule passes into the tulx;. From the 
 amphibia upwards, as a rule, the tulx; and ovary are separated, but in 
 •several species more primitive conditions arc found. In ornithorhynchus 
 each ovary has a peritoneal capsule, and the outer end of the tube is a 
 very wide funnel without fimbrixN J 
 
 In the Carnivora, in the rat, mouse, hyrena, guinea-pig, ass, rhino- 
 ceros, and some other mammals, the ovary lies in an ovarian sac of 
 peritoneum, which communicates with the peritoneum by an op)ening. 
 In the porcupine and baboon the sac is only partly L rmed. In the 
 highest mammals the ovarian sac is absent, though in the lemur a 
 rudimentary one is found. 
 
 In the lower vertebrates the outer end of the tube is a mere non- 
 fimbriated slit. In the Sauropsida and lower mammals it has a wide, 
 funnel shape without finiljriae. In the higher mammals the human 
 condition is usually found. In the sea-mammals, however, there are 
 no fimbriLC. 
 
 RELICS OF THE MESONEPHROS OR WOLFFIAN 
 BODY IN THE BROAD LIGAMENTS. 
 
 In their very full account of these relics Ballantyne 
 and Williams have pointed out the unfortunate confusion in 
 the nomenclature employed in their description. I shall 
 employ their terminology. 
 
 Organ of Rosenmiiller.^— In the adult this is a tri- 
 angular or trapezoidal mass of tubules, situated in the broad 
 
 ^ This term was introduced by \'^alentin. Synonymous with it is the 
 name of corpus pampiiiiforine^ used by Wrisberg, corpus conicum of 
 Rosenmiiller, parovarium of Kobelt, epoophoron of Waldeyer. 
 
 w 
 
WOLFFIAN RELICS. 
 
 15 
 
 ligament between the ovary and Fallopian tube, anterior 
 to the ovarian vessels. It consists of a basal longitudinal 
 duct, the remnant of the upper third of the Wolffian duct, 
 known as the duct of (lartner, situated close to the 
 Kallopian tube, and of a number of tubules extending 
 downwards from the longitudinal duct towards the hilum 
 of the ovary. The duct of (Jartner usually terminates 
 externally in a small cyst, sessile or pedunculated, known 
 as the hydatid of Morgagni ; its inner end approaches the 
 uterus, where it usually ends. Its wall consists of fibrous 
 tissue and a few smooth muscular fibres. It contains a 
 
 Fig. II. — Fallopian tube, ovary, and remains of 
 the Wolftian body in the adult. 
 
 lumen, lined with columnar epithelium, non-ciliated. In 
 the lumen cell debris may be found. The vertical tubules 
 may be divided into an inner and an outer group. The 
 former, twelve or more in number, mostly reach the hilum of 
 the ovary, though some fall short of it. They run towards 
 the ovary, being slightly tortuous in their upper part, and 
 appear to end in a small area, called by Rcsenmuller the 
 locus obsatrior. On microscopic examination this area is 
 composed of a network of the tubules — the rete ovarii, 
 some of which enter the ovary. The outer tubules, four or 
 five in number, run curved courses downwards and inwards, 
 not reaching the ovary ; they are known as the tubules of 
 Kobelt, and may give rise to small cysts. 
 
i6 
 
 7V/E FALLOPIAN TUBES. 
 
 I 
 
 The walls of the vertical tubules are made up of con- 
 nective tissue and a little smooth muscle. Few of them 
 contain a lumen. When this exists it is lined with 
 columnar epithelium in its upper portion and by cubical 
 epithelium near the ovary ; the latter are often ciliated. 
 In the outer group of tubules the lining cells are usually 
 cubical. 
 
 In the foetus and child the vertical tubes are much 
 convoluted in their upper portions. The outer group 
 do not reach the ovary, but end below in a sac-like pro- 
 jection of the anterior layer of the broad ligament — the 
 corptiscidum sacciforme of Rosenmiiller ; small cysts may 
 be sometimes found. The whole mass appears yellowish 
 grey by transmitted light. The vertical tubes have a lumen 
 lined with columnar epithelium in most cases. Between 
 the tubules small yellowish-grey masses may often be seen 
 — also mesonephric relics. Towards adult life atrophy of 
 the tubules takes place from within outwards, and from 
 below upwards. 
 
 After the menopause the organ atrophies, the vertical 
 tubules become shortened, straighter, and tend to disappear. 
 
 Other relics. — Between the organ of Rosenmiiller and 
 the uterus small grey opaque areas ^ are found, varying in 
 size from a millet-seed to a pea. They may also be found 
 between the duct of Gartner and the Fallopian tube, and in 
 some cases may be closely attached to the wall of the latter. 
 (In the child they may also be seen between the vertical 
 tubules.) Some of these masses are fibrous or fibro-fatty, 
 with traces of tubule remains, in the shape of canaliculi 
 or lumina filled with epithelium ; others consist of small 
 tubules lined with non-ciliated columnar epithelium. 
 
 These isolated masses are probably mainly derived from 
 the glomeruli of the primitive kidney. 
 
 Origin of these relics. — They are derived from the 
 Wolflfian body or mesonephros, composed of an upper or 
 ^ To these Waldeyer applies the i^xva. paroophoron ox parovarium. 
 
 \\ 
 
WOLFFIAN RELICS. 
 
 17 
 
 sexual part, and a lower or urinary part. Ballantyne and 
 Williams tabulate the various parts as follows, giving also 
 the male homologues : — 
 
 Foetus. 
 
 
 
 Adult Female. 
 
 Adult Male. 
 
 I. Upper part of 
 
 
 I. 
 
 ''2. 
 
 T lorizontal duct, duct of 
 
 ('• 
 
 1 
 Canal of 
 
 W 1 ffi a n = - 
 
 Gartner, or duct of 
 
 = ] 
 
 epididy- 
 
 duct 
 
 epoophoron 
 Efferent canals of epoo- 
 
 I 
 2. 
 
 mis testis. 
 Vasa effer- 
 
 
 
 phoron 
 
 
 
 entia. 
 
 
 \ 
 
 Tubular network, rete 
 
 
 ^^ 
 
 Rete testis. 
 
 1. Sexual part of 
 
 
 ovarii, locus obscurior 
 
 
 4- 
 
 T u b u 1 i 
 
 m e s n e- 
 
 
 
 4. 
 
 Masses of epithelial cells 
 
 =: ' 
 
 seminiferi 
 
 phros 
 
 
 
 in the hilum of the 
 ovary (medullary cords 
 of Waldeyer) 
 
 
 5- 
 
 testis. 
 Vasaber- 
 rans Hal- 
 
 
 
 ^S- 
 
 Isolated tubular relics 
 
 \ 
 
 leri. 
 
 
 
 
 
 r 
 
 Organ of 
 Oiraldes 
 (p a r a- 
 
 ;!. Urinary part 
 of mesone- 
 phros 
 
 |6. 
 
 Isolated solid relics in 
 broad ligament 
 
 ^ 
 
 6. 
 
 didyniis 
 of Wal- 
 deyer ; 
 parepi- 
 didymis 
 
 
 
 
 I 
 
 ofHenle) 
 
"v. 
 
 CHAPTER II. 
 
 THE UTERUS. 
 
 The uterus is a body resembling somewhat a flattened 
 pear. When the organ is dissected from its attachments 
 and viewed from the front or back, the upper end or 
 fundus is the broadest part and is convex, the lower end or 
 cervix being slightly conical and rounded. On each lateral 
 wall is a depression, marking the junction of the corpus and 
 cervix uteri ; this part of the uterus is called the isthmus. 
 
 Viewed laterally, the posterior wall is seen to be more 
 rounded than the anterior ; it has also a depression at the 
 level of the isthmus. At the junction of the fundus and 
 lateral walls the Fallopian tubes enter the body. Seen 
 from below, the appearance of the cervix varies accord- 
 ing to whether the woman has borne children or not. 
 If a nullipara, the os externum looks like a small rounded 
 dimple. If a multipara, it is a transverse slit, and some- 
 what irregular owing to Assuring. 
 
 Component parts. — The corpus uteri measures 2 in, 
 in width at the fundus and about i in. at the isthmus. 
 Its antero-posterior measurement is i in. The vertical 
 measurement from fundus to isthmus is 2 in. From the 
 isthmus to the os externum the length is i in. Transversely 
 the cervix measures about i in. in its widest portion. 
 
 The average thickness of the wall of the uterus is half an 
 inch, the posterior being slightly thicker than the anterior. 
 The walls are in apposition or are separated by mucus 
 secreted from them. 
 
 \\ 
 
COMPONENT PARTS. 
 
 19 
 
 flattened 
 ;achments 
 :r end or 
 ^er end or 
 ich lateral 
 orpus and 
 ^thmus. 
 
 be more 
 ion at the 
 ndus and 
 iy. Seen 
 s accord- 
 or not. 
 rounded 
 Ind some- 
 res 2 in. 
 isthmus, 
 vertical 
 ''rom the 
 Insversely 
 In. 
 
 Is half an 
 I anterior, 
 mucus 
 
 The cavity of the corpus uteri, as seen on sagittal mesial 
 [section, is a vertical slit, \\ in. in length. On coronal 
 Isection it is triangular in shape, the apex being at the 
 \os internum, the basal angles extending upwards and out- 
 irards towards the openings of the Fallopian tubes. On 
 transverse section, the cavity appears as a transverse slit. 
 The cervical portion of the cavity measures i in. in 
 length. It is somewhat narrowed at its upper and lower 
 ;nds. The os externum measures transversely nearly a 
 quarter of an inch ; antero-posteriorly slightly more. The 
 cavity, in its widest or antero-posterior diameter measures 
 
 Fig. 
 
 12. 
 
 -Different views of the uterus. 
 
 a. Vertical mesial section. 
 
 b. Coronal section. 
 
 c. The organ seen from the front. 
 
 d. Transverse section ot upper part 
 
 of body. 
 
 e. Transverse section of cervix. 
 
 [bout i^g in., and in its tran verse diameter slightly less than 
 
 quarter of an inch. The os internum measures about 
 
 in. in diameter. The diameter of the tube lumen at its 
 
 mction with the cornu is about -^-^ in. 
 
 That part of the cervix lying in the vagina is known as 
 
 le vaginal portion (portio vaginalis), the rest being the 
 
 ipravaginal portion. 
 
 * Schroeder divides the cervix into three parts, according to the attach- 
 ment of the vaginal walls. All above the level of attachment of the 
 -posterior vaginal wall is the supravaginal portion, that below the 
 level of attachment of the anterior vaginal wall the vaginal portion, 
 Srhile the part between these is the intermediate portion. 
 
20 
 
 THE UTERUS. 
 
 
 It is usual to speak of that part of the vaginal portion in 
 front of the os as the anterior lip, and of the rest as the 
 posterior lip. 
 
 Structure of the uterus. — Three coats are described 
 — peritoneal, muscular, mucous. 
 
 The peritoneal covering. — This will be considered 
 under "The Peritoneum" {vide p. 71). 
 
 The muscular part of the wall.— Tlr forms the main 
 portion of the uterus. It consists of interlacing bundles 
 of smooth muscular fibres. It is difficult to make out as 
 distinct an arrangement as in some of the lower mammals, 
 but the following may be described : — 
 
 (rt) An external layer, thinly developed, made up of 
 prolongations from the Fallopian tubes, the broad liga- 
 ments, the ovarian ligaments, the round and utero-sacral 
 ligaments. ', 
 
 (J)) An inner layer, well developed, in which the vessels 
 run, and which is continuous with the muscle of the 
 vagina. Between the muscle bundles are found elastic 
 and ordinary connective tissue. There is a special arrange- 
 ment of fibres around the inner ends of the Fallopian tubes, 
 OS externum, and os internum. 
 
 In the cervix there is a larger proportion of dense con- 
 nective and elastic tissue than in the body. It is thus 
 made very tough. 
 
 t 
 
 The Mucous Membrane. 
 
 I. Mucosa of the corpus uteri. — The mucosa of the 
 body of the nulliparous adult uterus has, when examined 
 fresh in the intermenstrual period, a fairly smooth surface, 
 a:nd is of a greyish-pink colour. With a low magnifying- 
 glass numerous small pits, the openings of glands, can be 
 seen. These vary in number in different places. 
 
 On microscopic examination, the thickness of the mucosa 
 is found to vary considerably in different parts. In my 
 
 w 
 
THE MUCOUS MEMBRANE. 
 
 31 
 
 specimens it varies from .5 to 2 mm. The average thick- 
 ness is probably somewhat greater in the multipara than in 
 the nullipara. In detail, the mucosa is best described under 
 the following headings : — 
 
 Lining epithelium. 
 
 Glands. 
 
 Interglandular tissue. 
 
 Linini:; epithelium. — This consists of ciliated columnar 
 I epithelial cells. Their nuclei are mostly elongated in the 
 direction of the long axis of the cell \ they are like short 
 
 
 Yw,. 13. — Section through the mucosa of tht^ corpus uteri 
 in the adult. A small portion of the muscular part 
 of the wall is also shown. 
 
 rods with rounded ends. Many are oval or ovoid ; a few 
 ire rounded. For the most part they are placed in the 
 ieeper portions of the cells, only a small amount of cell 
 substance being below them ; sometimes the nucleus is 
 juite close to the margin. In some cases it is situated in 
 ^he middle or outer division of the cell. The height of the 
 :ells varies. This variation is due to differences in the 
 imount of cell substance, or of nuclear material. In many 
 )laces small cells are found between the bases of the large 
 [uUy-formed cells. 
 
 In many carefully prepared thin sections a layer of 
 iattened connective tissue cells, belonging to the inter- 
 
u 
 
 22 
 
 THE UTERUS. 
 
 ■// 
 
 glandular tissue, can generally be recognised adhering 
 closely to the under surface of the layer of columnar 
 epithelium. It is to be regarded as a basement membrane. 
 In some specimens it cannot be distinguished. 
 
 Glands. — The glands are not uniformly distributed, being 
 more abundant in some parts than in others. They are 
 tubular, and are single or branched. The number of branch- 
 ings is usually only two ; sometimes more may be found. 
 The divisions occur mainly in the deepest portion of the 
 mucosa ; sometimes in the outermost portions, even close to 
 
 the surface. Very often 
 
 «J 
 
 i^ 
 
 they occur about the 
 middle of the mucosa. 
 Most of the glands 
 run obliquely to the 
 surface, some being 
 found, occasionally, al- 
 most parallel with the 
 
 Fig. 14.— Section of part of gland and surface. A few only 
 interglandular tissue of mucosa of corpus ^^^ ^^ -^^ ^^^^ ^^ 
 
 uteri. 
 
 the surface. 
 
 Some are straight, others slightly curved ; most are more 
 or less tortuous or wavy. 
 
 Of the latter, most are straight near the surface, but a few 
 are wavy in their whole extent. On transverse section the 
 glands are round or somewhat oval. 
 
 Most of the glands extend to the muscular part of the 
 uterine wall, some reaching it, others stopping a little short 
 of it. Here and there glands extend into the muscular 
 layer for varying distances. 
 
 The gland epithelium is of the same nature as that lining 
 the surface of tlie mucosa, though, on the average, its cells 
 appear to be a little larger. 
 
 The size of the epithelium varies in different glands. When 
 a surface view is obtained, the outlines of the cell ends appear 
 to be more or less lounded, though some are quite irregular. 
 
 t 
 
 i\ 
 
INTERGLANDULAR TISSUE, 
 
 aj 
 
 le mucosa. 
 
 are more 
 
 I titer glandular tissue. — This forms the main portion 
 of the mucosa. Its line of junction with the muscle of the 
 uterine wall is an irregular one. Muscular projections of 
 different lengths extend into the deep portions of the 
 mucosa. 
 
 It is composed of connective tissue of a low or embry- 
 onic type. It is best described as consisting mainly of 
 delicate anastomosing nucleated masses of protoplasm. In 
 some parts it is like a network with well-marked spaces, the 
 anastomosing filaments being very fine. In other parts the 
 matrix is almost a homogeneous mucoid-like mass, con- 
 taining rounded nuclei, very few spaces being seen, or 
 scarcely any differentiation into distinct cells. 
 
 In general, however, more or less distinction exists 
 between the cells, though, for the most part, they remain 
 connected by strands of matrix of various sizes. Close to 
 the surface of the mucosa, the cells are usually flattened 
 parallel to it. The larger the cells the more elongated 
 they are. 
 
 The nuclei are rounded or oval in general, the matrix 
 surrounding them being irregular in shape, and possessing 
 one or more branching processes. Here and there groups 
 of cells are found which are rounded, oval, or spindle- 
 shaped, with no anastomoses. Often the nuclei may be 
 seen dividing. (This embryonic appearance of the inter- 
 
 i glandular tissue becomes more or less altered in chronic 
 
 I endometritis.) 
 
 Close to the epithelium of the glands and to that of the 
 
 [surface is a layer of flattened cells forming a basement 
 
 ! membrane. To it the epithelium appears to be attached. 
 
 Arteries and veins extend from the muscular part of the 
 wall into the mucosa for varying distances. The former 
 run a tortuous or wavy course usually ; the latter a straighter 
 
 i course. At what level they pass into the capillaries, which 
 
 [supply the outer layer of the mucosa, it is difficult to say. 
 
 I As a rule, this seems to take place just outside the middle 
 
H 
 
 THE UTERUS. 
 
 part of the mucosa. In the outer part I can only find 
 capillary vessels, mere tubes of flattened endothelium. 
 
 Occasionally a small arteriole, with scarcely any wall 
 outside the endothelium, may be found in the outer portion 
 of the mucosa. 
 
 In some cases the capillary wall may have one or more 
 layers of flattened cells of the interglandular tissue sur- 
 rounding it. 
 
 It is this appearance which has often been wrongly 
 described by observers, who have supposed the vessels to 
 be arteries. Arteries occur only exceptionally in the outer 
 mucosal region. There it is chiefly capillaries that are found. 
 
 According to Minot the capillaries form a network 
 around the glands. If he means that a special vascular 
 mesh is particularly noticeable around them, I cannot 
 agree with him. They are found no more numerous near 
 the glands than in any other part of the interglandular 
 tissue, in which they are distributed in no uniform manner. 
 
 As to the lymphatics, I am in agreement with Leopold. 
 The spaces in the interglandular stroma contain lymph, and 
 they are drained by lymphatics proper, which begin in the 
 deeper layers of the mucosa or in the muscle. In these 
 spaces leucocytes are found, varying greatly in numbers in 
 different parts. 
 
 In conclusion, I would point out that the mucosa might 
 well be described in terms which are generally only used in 
 reference to the altered condition of pregnancy, namely, com- 
 pact and spongy ; the former being the outermost portion, 
 in which the glands have not, for the most part, begun to 
 divide ; and the latter being the deeper portion, in which 
 are the branchings of the glands. Strictly, the spongy layer 
 might be considered as consisting of two parts, an outer 
 and a deeper, the latter being that next the muscle con- 
 taining the most numerous gland spaces. 
 
 The following points regarding the mucosa of the body 
 of the uterus should be kept in view : — 
 
MUCOSA OF THE CERVIX UTERI. 
 
 as 
 
 ( 1 ) Its thickness is not uniform, but varies considerably. 
 
 (2) The Hning cells show variations in their height, their 
 thickness, the shape, size, and position of their nuclei. 
 
 (3) The same may be said of the cells lining the glands. 
 In general these are larger than the surface cells. 
 
 (4) The interglandular tissue is mainly embryonic in 
 nature, consisting of a nucleated protoplasmic reticulum. 
 Here and there are found all stages of transformation to the 
 more advanced spindle-shaped cells. 
 
 (5) The cells nearest the surface are mostly arranged 
 parallel to the surface. A special hyer of these exists as a 
 distinct basement membrane, and is generally found un ler 
 the surface epithelium, as well as under that lining the 
 glands. 
 
 (6) In the outer layer of the mucosa, the capillary junc- 
 tions of the arteries and veins are the only vessels usually 
 found. 
 
 (7) The line of junction of mucosa and muscular wall is 
 an irregular one. There is no special muscularis mucosre. 
 
 2. Mucosa of the cervix uteri. — When the cervix 
 is opened by a vertical incision, the mucosa, red 
 colour, is seen to be arranged 
 in a series of folds On the 
 anterior and posterior wall is 
 a vertical ridge with branching 
 
 [ridges extending from it — the 
 ')Ucce palmatce, the whole ar- 
 
 Irangement being known as the 
 
 \arf)or vihe. This does not ex- 
 
 jtend above the os internum, 
 
 [but stops short of it usually. 
 
 The mucosa is lined with 
 
 [columnar epithelium, ciliated on the prominent parts of the 
 ridges. Glands communicate with the cervical canal. They 
 ire short depressions with lateral diverticula. The outline of 
 jach gland is thus serrated in longitudinal section. They 
 
 m 
 
 Fig. 15. — Section through a por- 
 tion of mucosa of cervix uteri. 
 
I 
 
 a6 
 
 THE UTERUS. 
 
 are lined with columnar epithelium, more or less ciliated, 
 lying on a basement membrane. In the upper part of the 
 cervix, the glands tend to resemble those of the corpus in 
 type. The region of the os internum is, in fact, a transition 
 area. Just within the os externum the transition between 
 the columnar epithelium lining the cervical canal and the 
 stratified squamous epithelium which covers the vaginal por- 
 tion takes place. The latter has a pinkish-grey colour, very 
 different from the red cervical mucosa. 
 
 The uterus at different periods of life. — At birth, the corpus is 
 only slightly developed, being about one-third the length of the cervix, 
 and of smaller width. It is usually bent slightly forward. The arbor 
 vitce extends to the fundus. This condition is found up to the period of 
 puberty, with the exception that the lateral ridges of the ar'or vitoe 
 disappear from the mucosa of the corpus, and only a median ridge is 
 left. At puberty the body increases in size until it reaches the normal 
 adult relationship of the cervix. 
 
 In the nuUiparous adult the uterus is smaller and less rounded than 
 in the multipara. The external signs of the junction of corpus and 
 cervix are better marked in the former. In the latter the cavity is 
 wider, and its triangular shape, as seen on coronal section, is less clearly 
 defined. The os internum is less pronounced, the cervix is slightly 
 shorter, the os externum is a transverse slit, irregular from fissures. In 
 a uterus which has passed through only one labour, the cervix not 
 having been torn, it may be very difficult to distinguish it from a nuUi- 
 parous one, after several years have passed. 
 
 After the menopause the uterus diminishes in size, and becomes hard, 
 owing to the sclerosis in the connective tissue elements. The mucosa 
 thins, the epithelial cells get smaller, lose their cilia, and may gradually 
 disappear. The cervical glands are lost, and also those of the corpus to 
 a large extent. Those which remain get completely surrounded and 
 form small cysts. The interglandular tissue becomes dense and fibrous. 
 
 Position of the uterus. — In the great majority of cases 
 the uterus is placed in the anterior half of the pelvis 
 (anteposed). When the bladder is empty it lies so that 
 the fundus is directed forwards (anteverted), there being 
 a slight curve on the organ, the concavity being on the 
 anterior surface (anteflexed). 
 
 It may lie exactly in the middle line, but is often, as a 
 
 ! V 
 
ITS POS/T/OX. 
 
 vj 
 
 whole, found somewhat to the right or left (more often the 
 latter, according to VValdeyer). In some cases the long 
 axis may not be sagittally placed, but may be directed so 
 that the fundus looks slightly to the left or right (lateri- 
 vcrtcd). In rare cases the organ may be situated far back 
 in the pelvis (retroposed). In other cases retroversion may 
 be a congenital condition. Very rarely in childhood the 
 anteverted uterus may be also retrofiexed. 
 
 Fiu. i6. — Vertical or sagittal mesial section through 
 the pelvis of nullipara. 
 
 As regards rotation of the healthy nulliparous uterus there 
 has been some discussion. In using this term it is neces- 
 sary to distinguish between inherent or true, and secondary 
 or accidental rotation. By the former I mean a quality 
 [impressed upon the organ in its development and 
 growth. It is only found occasionally. In the living 
 subject a slight degree of rotation cannot be determined 
 by physical examination. One cannot be sure 'hat a 
 supposed rotation is not caused by artificial disturbance 
 
a8 
 
 THE UTERUS. 
 
 I 
 
 of parts. Moreover, one cannot definitely eliminate acci- 
 dental causes of rotation, e.^. altered states of intra-abdo- 
 minal pressure, varying conditions of distension of bowel 
 or bladder, old peritonitic or cellulitic cicatrisations. It 
 is important to note also, that ordinary post-mortem ex- 
 amination is not satisfactory in the determination of the 
 exact relation hips of the uterus nor of any other organ. 
 (Frozen sections are necessary.) 
 
 According to some writers this alleged characteristic in 
 the uterus is the result of a tendency to torsion possessed 
 by most structures in the body. No doubt this tendency 
 does exist in certain parts, but its significance is not 
 clear. 
 
 As regards the uterus, were long-axis rotation one of its 
 growth characteristics we should expect to find it in the 
 great majority of cases. As it is, we find it extremely 
 rarely. 
 
 A careful study of the work of Ernst Fischer, the great 
 authority on the subject of torsion, teaches us that we are 
 not justified in referring this tendency to the human uterus. 
 
 Fischer's remarks refer to the organ, not in its single 
 well-formed condition, but in its composite capacity as a 
 double organ, formed by the blending of two lateral halves. 
 
 Fischer's description of a tendency to spirality in the 
 uterus refers to each half, and he does not speak of a 
 torsion of each Miillerian duct as a whole, but only of 
 ^'^ muscular bundles. These, he says, show a tendency to 
 jdromous spirality, according to the general law which 
 .. has formulated, namely, that structures in the right half 
 of the body show a lef*" spiral, and those in the left half a 
 right spiral arrangement. His conclusions are derived from 
 the study of animals with double uterus, and of cases of 
 bicornuate uterus in women. \ 
 
 In early foetal life there is no rotation distinguishable in 
 the Miillerian ducts. But if this did exist we should expect 
 that, after blending occurred, there would be no torsion in 
 
NORMAL MOVEMENTS. 
 
 »9 
 
 the single organ, because of the neutralisation of right and ■ 
 left liomodromous characteristics. 
 
 The foldings in the early Fallopian tubes develop after 
 the fusion of those parts of the Miillerian ducts which 
 give rise to the uterus. Nagcl states that they are due to 
 the rapid incr'iase in their length. 
 
 Embryological explanations as to relationships of uterus. — 
 
 In early fiiibryonic life the Miillcriiin ducts have sini])ly a curve 
 corrcsponiling to that of the body. When they have reached the uro- 
 genital sinus, and have become blended with the Wolffian ducts to form 
 the genital cord, the latter, at the part which afterwards l)ecomes the 
 uterus, forms a curve, whose concavity looks forward. The angle of 
 the bend is at the part which becomes os externum (Nagel). This 
 continues through development, the part above the angle forming the 
 uterus. The condition is somewhat altered by the sinking down of 
 the genital cord, and by the pressure of the intestines on the upper 
 part t)f the uterus. A flexion tends to be especially marked on the 
 upper part of the uterus, owing to the bending forwards of the small 
 fundus. In the later months of embryonic life this condition is usually 
 well-marked, though the angle of flexion varies according to the condi- 
 tion of the bladder. 
 
 In the adult state the attachments and relationships of the uterus are 
 of such a nature as to explain why the normal conditions should be 
 found. The cervix is more fixed than the body. It is slung in a 
 bridge formed chiefly by the utero-sacral ligaments, the liladder and its 
 ligaments. The body has a considerable range of movement, owing to 
 the laxity of its connections. Born with a tendency to antcversion and 
 anteflexion, the erect posture of the body and intra-abdominal pressure 
 continue this. Probably the round ligaments, owing to their length, 
 exert very little influence normally on the uterus. 
 
 Throughout the mammals the anteverted condition of the uterus is 
 found. 
 
 Normal movements of the uterus. — The uterus is 
 continually moving — ^with each respiration, in walking, in 
 singing, and in all actions which alter the relationship of 
 intra-abdominal pressure to the organ. It changes in 
 accordance with the emptying or filling of the bladder, and, 
 to a certain extent, is affected by the distending rectum. 
 The uterus and bladder behave practically as one organ in 
 
I 
 
 30 
 
 THE UTERUS. 
 
 normal conditions. The anteflexion becomes less marked 
 as the bladder raises the fundus. 
 
 The uterus can be made to move artificially through a 
 considerable range. It can be pushed up about \\ in. ; 
 it can be pulled down until the os externum is near the 
 introitus vaginae. 
 
 Special ligaments of the uterus. — The broad ligaments 
 are described on p. 71. 
 
 The round ligaments are two flattened cords, 4 or 
 5 in. in length, which extend from the upper angles 
 of the uterus in front of the inner ends of the Fallopian 
 tubes. Each one passes upwards, outwards, and forwards. 
 
 I 
 
 ■I 
 
 Fig. 17. — Displacement of uterus 
 by distended bladder. 
 
 Fig. 18. — Displacement of uterus 
 by distended rectum. 
 
 invested with a covering of peritoneum continuous with 
 the anterior layer of the broad ligament. It goes through 
 the inguinal canal, and is directed towards the pubic spine, 
 where it blends with the tissues of the mons veneris and 
 labium majus. It is composed of connective and elastic 
 tissue ; there is also some non-striped muscle, mainly in its 
 inner portion, derived from the outer layer of the uterine 
 musculature. 
 
 In the inguinal canal it gains a few striped muscular 
 fibres, which arise from the internal oblique and trans- 
 versalis abdominis muscles, as well as from the pubic spine ; 
 
 f \ 
 
DEVELOPMENT. 
 
 31 
 
 these correspond to the cremaster muscle in the male. The 
 part of the ligament outside the canal has no muscular fibres. 
 
 Developmental note. — In the fcetus its early covering of perito- 
 neum projects as a tubular process into the inguinal canal. The 
 peritoneal tube thus formed is called the canal of Nuck. It is some- 
 times permanent throughout life, though, generally, it becomes obliter- 
 ated. It corresponds to the processus vaginalis in the male. When 
 present after childhood it is a predisposing cause of hernia. 
 
 The utero-sacral ligaments are two peritoneum-covered 
 bands, which pass from the outer parts of the posterior 
 surface of the upper third of the cervix, outwards, 
 upwards, and backwards, to the upper part of the th'rd 
 sacral vertebra, sometimes higher. The inner margin of 
 I)eritoneum is thin, and forms the upper boundary of the 
 pouch of Douglas. The essential part of each ligament is a 
 flat band of muscle running along its outermost part. This 
 band is called the utero-rectal muscle^ or the muscular re- 
 tractor of the uterus. The projecting portion of the ligament 
 contains scarcely any muscle ; it is made up of loose con- 
 nective tissue, which is continuous with the paraproctal and 
 parametric tissues. Posteriorly the tissues of the ligament 
 I blend with those surrounding the rectum. The function of 
 I these ligaments is considered on p. 92. 
 
 Development. — The uterus develops out of the MUllerian ducts 
 
 Ibelow the round ligaments. — The development of the ducts has already 
 
 ibeen described. By the end of the third month the blending of the 
 
 lower portions, by absorption of the contiguous inner walls, is complete. 
 
 This takes place as far up as the attachment of the round ligaments. 
 For a time the uterus presents the external sign of its double origin, 
 
 ifhile at the part which afterwards becomes the fundus, there ic a 
 
 iistinct indentation. 
 
 The lumen is lined with high columnar epithelium. The lower end 
 4s closed, and is composed of large irregularly rounded cells. This 
 
 lass, on reaching the urogenital sinus, pushes forward its posterior wall 
 md forms *he eminence of MUller ; from this mass of cells is developed 
 jthe vagina {vide p. 36). The two varieties of cells pass gradually into 
 jne another. As the embryo grows, the distinction becomes sharper. 
 
 ?he junction between the two is the anlage of the os exteinura. 
 
32 
 
 THE UTERUS. 
 
 \ 
 
 Another difference becomes marked between the two portions of the 
 genital tract, namely, in regard to their position. The lower or vaginal 
 portion tends to be directed from above downwards and forwards ; the 
 upper or uterine portion upwards and forwards. 
 
 A differentiation also tends to become marked between the epithelium 
 of the corpus and that of the cervix uteri. The former is less elevated 
 than the latter, which is at first of several layers, the surface outline 
 being wavy. This appearance is produced by the sinking inwards of 
 the epithelium to form the glands of the cervix. 
 
 These cervical glands develop in the last half of intrauterine life. 
 The glands of the corpus begin to develop just before birth, or soon 
 
 afterwards ; they are usually very 
 scanty until puberty. No cilia are 
 found on the cells at birth. 
 
 In the differentiation of cervix from 
 vagina, the posterior lip of the former 
 first develops by the extension outwards 
 and upwards of a sickle-shaped projec- 
 tion of the large rounded epithelial 
 cells, just below the columnar cells. 
 The anterior lip is then formed. The 
 non-epithelial portion of the uterus 
 is developed from the mesoblast 
 which surrounds the epiblastic tube. 
 According to Nagel, the muscle 
 fibres do rot develop before the fifth 
 month. 
 
 Notes on the Mullerian tracts 
 in the vertebrata.— In the Elasmo- 
 branchii, the Mullerian and Wolffian ducts are distinct, and open 
 into a cloaca, as does the rectum. 
 
 In the Ilolocephala, where there is no cloaca, the distinct orifices of 
 the Midlerian and Wolffian ducts open posterior to the anus. 
 
 In the Ganoidei, where there is no cloaca, the urinary and genital 
 ducts open externally by a common aperture. In the Teleostei, the 
 genital ducts have a single opening anterior to and distinct from the 
 opening which communicates with the urinary ducts. In the Dipnoi, 
 the blended lower ends of the Miillcrian ducts open along with the 
 ureters into a cloaca. 
 
 In the Amphibia the Wolffian and Mullerian ducts are distinct, and 
 communicate independently with the cloaca. 
 
 In the Sauropsida the Mullerian ducts open independently or united, 
 into a cloaca. 
 
 Fig. 19. — Veitical mesial 
 section through pelvis of a 
 foetus. 
 
 I \ 
 
THE VAGINA. 
 
 33 
 
 Among these various classes it is important to note the existence in a 
 tw cases of a uterus or brood sac. Thus in Sqitatina angeltcs, a dog- 
 sh the lower united ends of the Miillerian ducts form a dilatation in 
 ^hich the young are developed for a period. 
 
 The same thing is found in certain other fishes, and in several 
 
 iphi!)ians and reptilians. Thus in Salamatidra maculosa each 
 
 [iillerian duct, immediately above the cloaca, has a dilated portion in 
 hiich the young develop. In these cases, it is to be noted, the uterus 
 brood sac is close to the outlet, there being no intervening vagina. 
 Lmong the Mammalia various conditions are found. 
 
 In the lowest order is the ornithorhynchus, in which the Miillerian 
 kcts open separately into the urogenital canal, distinct from the open- 
 jg of the urethra. The vagina is apparently not represented, the lower 
 
 ids of the ducts corresponding to the os externum ; they project some- 
 what like the portio vaginalis in the Primates. It is very interesting to 
 
 3te the presence in the virginal condition of hymeneal membranes 
 ^hich close the lower ends of the ducts, a very clear proof that a 
 
 niK'n may be formed between the urogenital canal and the Miillerian 
 
 act. 
 
 ^'^, In the Marsupialia are found, generally, separate Miillerian ducts, 
 fach of which consists of a uterine and a vaginal portion. We find 
 feerc, however, the first traces of blending. Thus, in Macroptis majors 
 separate vaginre blend in their upper portions in a kind of sac, into 
 lich the uteri open. 
 
 (in all the other mammalian orders, the vagina is single. It is 
 
 jident, then, that the higher we advance in the mammalian series, we 
 
 |d the uterus later in becoming single than the vagina. The first 
 
 3earance of union in the uterine cornua is in the marmot, in which 
 
 tfeiey are bound together at their lower ends for a short distance. 
 
 > In Capromys pelorides there is a single portio vaginalis with one os 
 estternum, though both uterine canals communicate with it. The next 
 stege is the development of a single cervical canal, found in many 
 mammals, e.g. Phoacna. 
 
 In the Primates, the uterus is single and pyriform, except among the 
 temuridcE, in which it is bicornuate. 
 
 THE VAGINA. 
 
 The vagina is a canal in the pelvic floor. It forms the 
 
 jgetssage from the cervix uteri to the surface of the body. 
 
 In front is the bladder and urethra, behind the rectum and 
 
 ^us. In the normal adult, the vagina is about parallel 
 
 3 
 
I J 
 
 34 
 
 THE VAGINA. 
 
 I 
 
 with the plane of the pelvic brim. Ordinarily, the walls of 
 the vagina are in apposition from before backwards. The 
 anterior wall is shorter than the posterior by the thickness 
 of the cervix, which is attached to the upper end of the 
 vagina. The measurements vary somewhat, the anterior 
 wall being 2| to 3^ in. (7-8 cm.), and the posterior 3I to 
 4 in. (8-10 cm.). The vaginal slit is widest in its upper 
 part, and narrowest near the hymen. 
 
 On vertical mesial section, it has a sigmoid shaps ; on 
 transverse section, near the cervix, it is bow-shaped ; in the 
 middle portion, H-shaped, and near the hymen it is an 
 irregular transverse slit. 
 
 The upper end of the vagina is known as the vault or 
 fornix. It contains the cervix uteri, whose os externum 
 looks normally downwards and backwards. It is customary 
 to divide the fornix into four parts in relation to the cervix, 
 namely, anterior, posterior, right lateral, left lateral. The 
 posterior fornix is the deepest, owing to the higher attach- 
 ment of the vaginal wall to the '•'^rviA posteriorly, namely, at 
 the junction of the lower two-thirds and upper third ; the 
 anterior wall is attached at the junction of the lower third 
 and upper two-thirds. 
 
 Structure. — i. The lining 7nembrane (so-called mucosa). — 
 This consists of a sub-epithelial layer of loose connective 
 tissue and a covering layer of stratified squamous epithelium. 
 It is thin, and like skin, except that the stratum corneum is 
 wanting. The epithelium is continuous with a similar layer 
 on the vaginal portion of the cervix, on the hymen, and ex- 
 ternal genitals. Normally no glands are found in the vagina. 
 
 In the nullipara the wall of the vagina is markedly 
 rugose, especially in the lower portion. Here is found a 
 mesial ridge or fold, from which transverse ridges extend. 
 The mesial column on the anterior wall is often double, 
 and is usually longer than the posterior; as it is so in- 
 timately related to the urethra it has been termed the carina 
 iirethralis vagince. 
 
STRUCTURE. 
 
 35 
 
 Numerous papillns are found on the vaginal walls. In 
 he sub-epithelial tissue of these are found networks of 
 apillary blood vessels. 
 
 2. 21ie muscular part of the wall. — There has been 
 
 ome dispute as to the arrangement of the muscular layer 
 
 f the wall. The main layer is one of smooth fibres, mainly 
 
 rranged longitudinally, but many fibres are found running 
 
 other directions. It is continuous with the uterine 
 
 usculature. It is stated by some that a special thin 
 
 nternal layer can often be made out. 
 
 At the vaginal outlet a special subcutaneous muscle has 
 
 een described by Luschka, the so-called sphincter vagina. 
 
 t is thin, i to ;^ in. broad, and embraces in a forked 
 
 lanner the urethral orifice and the introitus vaginae. 
 
 xternal to the muscle is soft connective tissue and a 
 
 in layer of the pelvic fascia. 
 
 Physiological note. — The vagina serves as a collecting 
 lace for the semen in copulation, and forms a passage for. 
 e child during birth. It is, under ordinary conditions, 
 erely a potential tube, its walls being in apposition. It is 
 pable of great dilatation. This is especially seen during 
 hour, and is due to the fact that U.\ere is a great deal 
 loose tissue surrounding it, that the epithelial layer is 
 oscly attached to the muscular, that there are many fold- 
 gs of the inner layer, and that its wall is exceptionally 
 h in lymphatics, I which much fluid can soften the 
 sues. 
 
 As there are no glands in the vagina, it is kept moist 
 
 m the uterine secretion which runs into it ; and, also, 
 
 the transudation of fluid from the sub-epithelial lymph 
 
 ssels. The latter factor is most marked in pregnancy. 
 
 The secretion ordinarily found in the vagina is acid. The 
 
 rmal secretion of the uterine mucosa is alkaline. Con- 
 
 quently a change occurs in the vagina. This is probably 
 
 e to the action of the numerous microbes which flourish 
 
 ere. 
 

 il 
 
 \< 
 
 36 
 
 THE VAGINA. 
 
 Development of the vagina. —According to most observers its 
 development occurs as follows : — 
 
 Attention has already been directed to the differentiation of the 
 epithelium, which is early found ni the lower end of the Miillerian 
 ducts {vide p. 31); the lumen of the duct possessing columnar 
 epithelium, the solid end below consisting of large polygonal cells. 
 This end has been described as projecting outwards to the wall of the 
 urogenital sinus, as Miiller's eminence. This spot marks the future 
 hymen, the centre of the mass of cells gradually breaking down. 
 
 At first the vagina is very short, i mm. in length. It gradually 
 elongates pari passu wi' ' the formation of the urethro-vaginal septum 
 and shortening of the urogenital sinus. As it does so, its epithelial 
 cells become somewhat smaller, those next the mesoblast getting to lie 
 in regular rows, those furthest from the mesoblast becoming flattened. 
 There is as yet no distinct lumen. In an embryo at the third month 
 may be seen, at the lower end of the solid vagina, an accumulation of 
 the flattened central cells to form a bulbous mass clear in the centre, in 
 which afterwards the cavity of the vagina is formed. External to this 
 mass is a thin partition, which afterwards forms the hymen ; its central 
 portion usually gets absorbed. 
 
 Hart has shown that this takes place by multiple tubular ingrowths 
 of epithelium covering the wall of the sinus, i.e. the outer surface of the 
 hymen. 
 
 This process of increase of the central stratified cells, followed by 
 absorption, gradually extends up towards the cervix, and takes place in 
 such a manner as to lead to the formation of the rugoe on the vaginal 
 walls, and on the vaginal portion of the cervix. This is completed by 
 the sixth or seventh month. The rugoe can be seen on the cervix at 
 birth. At this time cast-off portions of the stratified epithelium are 
 found lying in the vagina. The muscular fibr s first appear in the 
 outer part of the vaginal wall about the fifth month, the same time as it 
 is first seen in the uterus. 
 
 Berry Hart's view. — Recently Berry Hart has advanced the fol- 
 lowing view : — 
 
 Until the third month of foetal life, the vagina is formed by the 
 coalesced Miillerian ducts, ending blindly at their lower end ; there is 
 then no lower aperture, no hymen. 
 
 In the beginning of the third month a proliferation of the epithelial 
 lining of the lower ends of the Wolffian ducts takts place, forming Avhat 
 he calls the Wolffian bulbs ; peripheral cells are active, the central ones 
 become less active and arranged in layers of squamous cells, resembling 
 the structure of the vaginal epithelium at full time, as in the adult 
 state. 
 
 (V 
 
DEVELOPMENT. 
 
 37 
 
 lOst observers it., 
 
 rentiation of the 
 of the Miillerian 
 essing columnar 
 
 polygonal cells. 
 to the wall of the 
 Tiarks the future 
 making down. 
 :h. It gradually 
 o-vaginal septum 
 so, its epithelial 
 last getting to lie 
 coming flattened, 
 the third month 
 1 accumulation of 
 • in the centre, in 
 
 External to this 
 ■men ; its central 
 
 :ubular ingrowths 
 iter surface of the 
 
 Us, followed by 
 d takes place in 
 ;ae on the vaginal 
 is completed by 
 on the cervix at 
 epithelium are 
 ;t appear in the 
 same time as it 
 
 ^lie bulbs coalesce and break down in the centre ; at the same time 
 tir proliferating epithelium spreads up the Miillerian canal, displacing 
 
 epithelium, maps out the fornices, and covers the vaginal portion of 
 
 ' cervix, along with a small part of the lower end of the cervical canal. 
 L' hymeneal opening is brought about by the epithelial involution 
 Im the urogenital sinus meeting the distended Wolffian bulbs. 
 
 [lart believes that the Wolffian ducts are epiblastic in origin, and 
 It this is the explanation of the skin-like covering of the vagina and 
 
 'inal portion of the cervix. The outer part of the hymen is, there- 
 re, derived from the urogenital sinus, the inner part from the 
 rolffian bulbs. 
 
 Changes in the vagina after puberty. — In a woman 
 lo has been subjected to coitus for some years, the vagina 
 somewhat stretched, and the walls made less rugose than 
 [the nuUiparous condition. In a woman who has borne 
 ildren, these features are very much more marked ; in- 
 ;d, the rugose condition may entirely disappear. After 
 menopause, the lumen shrinks in size, mainly in the 
 cr part, so that it becomes somewhat conical, the vaginal 
 rtion of the cervix remaining as a very small papilla, 
 jn scarcely recognisable to touch. In a multipara the 
 lis become smooth at this time. 
 
 In a woman who has married late and has become 
 ^gnant, the vaginal walls do not, as a rule, become so 
 and distensible as in a young woman. They are of 
 kgher texture. 
 
 Ivanced the fol- 
 
 formed by the 
 er end ; there is 
 
 of the epitheli.ll 
 e, forming what 
 the central ones 
 ells, resembling 
 as in the adult 
 
 THE HYMEN. 
 
 (n the nullipara the hymen is usually a thin circular 
 
 forated membrane, which separates the vagina from 
 
 vulva. It consists of connective tissue, covered on 
 
 th sides with stratified squamous epithelium. 
 Variations are found as regards the position of the 
 len, according to the depth of the vestibule. In negro 
 
 lien the deep vestibule is common, the hymen, there- 
 
 5, appearing rather far from the vulva. 
 
v\ 
 
 38 
 
 THE HYMEN. 
 
 \ 
 
 Usually, the free margin projects outwards, the inner 
 surfaces of the lateral halves being more or less in apposi- 
 tion. Sometimes it is formed as a projecting collar. The 
 opening in the hymen is visible when the vulva is opened 
 and the labia put on the stretch. 
 
 The opening is rarely central. Usually it is nearer the 
 anterior than the posterior margin ; often it is so far forward 
 as to give the hymen the shape of a half-moon. The free 
 edge is smooth or irregular. Sometimes there is a double 
 opening, one being in each half. Occasionally, only a small, 
 round opening or vertical slit is found, or there may be 
 several small openings. Sometimes the slit is oblique, 
 the left lip being rather posterior, and the right anterior. 
 When the opening is very large, the hymen has a falciform 
 shape. Sometimes the margin is notched so as to form the 
 denticulate hymen. This may be taken for a lacerated 
 hymen ; the notches, are, however, usually regularly placed, 
 two being in front and two behind (Pozzi), and the free 
 border can be shown to have no traces of cicatrisation. 
 Sometimes only one notch is found, sometimes two ; in 
 the latter case a tongue-shaped projection may be formed, 
 giving rise to the Ungulate hymen. Rarely a fringed 
 hymen is found. Sometimes there is a thick band on the 
 posterior part of the hymen — a prolongation of one of the 
 columns of the vaginal walls, especially the posterior. 
 
 The size of the opening varies as well as the distensi- 
 bility of the hymeneal structure. Ordinarily a finger can 
 be passed into the vagina gradually without causing pain, if 
 the hymen be not stretched by very wide separation of the 
 legs. In all cases continued coitus causes a stretching of 
 the structure, and, in most instances, laceration, varying in 
 amount in different cases. 
 
 According to Brouardel and Laugier, a laceration of the 
 hymen may heal completely, so as to appear uninjured ; on 
 careful examination, however, the white cicatrix may be 
 found. 
 
INFANTILE HYMEN. 
 
 39 
 
 After the birth of a child it is usually torn and changed 
 |to a number (usually three to six) of tags, known as the 
 Xcarunciihe myrtiformes. This may also take place after a 
 I miscarriage, to a certain extent. But it is important to note 
 that often after a miscarriage, and occasionally after a full- 
 jtime labour, no appearance of tearing may be visible, only 
 [great stretching having taken place. 
 
 Infantile hymen. — In the infant the hymen is relatively 
 [somewhat more deeply situated than in the adult, owing to 
 the depth of the vestibule. As compared with the adult 
 condition it is, relative to the size of the labia, rather largely 
 developed, and may sometimes be mistaken for the labia 
 i minora. Usually it projects forwards, like the inverted 
 finger of a glove, or with the lateral halves in apposition 
 by their inner surfaces ; it may be annular, or be folded 
 like a tobacco-pouch (Pozzi). The rugae and pillars of 
 [the vagina are prolonged upon the posterior wall. 
 
 In young girls, if the thighs be widely separated, the 
 [hymen is stretched, and is rendered more difficult to 
 [penetrate. If they be brought together, the hymen 
 [may be considerably stretched, so that sometimes a finger 
 or even a penis may be able to enter the vagina 
 [(Brouardel). 
 
 Sometimes a congenital condition is found in which there 
 [is quite a depression external to the hymen, above the 
 Ifourchette. A similar appearance has also been described 
 [by Dolbeau as the result of attempts at intercourse, when 
 [penetration of the hymen was not effer d. 
 
 According to Pozzi, there may be very often seen in 
 [children (and sometimes in the adult), a kind of hymen 
 surrounding the urethra continuous with a raised band 
 (which is composed of two lateral halves), which is again 
 continuous with the collar of the hymen at the entrance 
 of the vagina. According to Pozzi, this whole hymeneal 
 arrangement is the homologue of the corpus spongiosum 
 in man, the mesial band being known as the male vesti- 
 
40 
 
 THE EXTERNAL GENITALS, 
 
 
 
 bular band, and corresponding to the frenum found in male 
 hypospadias. 
 
 Comparative note. — In none of the lower mammals is a distinct 
 circular hymen found, though in many — e.g. horse, cow, pig, elephant, 
 monkey, etc. — a constriction marks the lower end of the vagina. 
 
 In several, an antero-posterior band is found— a condition sometimes 
 found in woman. In mice a plug of epithelial cells closes the lower 
 end ; this is renewed after each labour. I have already pointed out 
 that in ornithorhynchus the lower end of each uterine duct is closed by 
 a membrane. 
 
 Development of the hymen. — Various views are held : — 
 
 1. For a long time it has been held by many that the hymen was a 
 mere projection of the vaginal walls (Ulandin, Henle). 
 
 2. Pozzi, who regards the hymen anrl the rest of the hymeneal 
 apparatus described above as the homologue of the corpus spongiosum 
 in man, describes the hymen as being developed from part of two 
 lateral elongated projections, arising from the junction of the vagina 
 and urogenital sinus, extending as far forwards as the clitoris. These 
 advance towards the middle line and blend completely in front of the 
 vaginal and urethral orifices, the median blended portion left in the 
 middle line of the vestibule being known as the male vestibular band. 
 
 The first distinct trace of this development is found at the nineteenth 
 week. When complete, the male vestibular band, the urethral hymen, 
 and the vaginal hymen may be recognised. 
 
 3. According to most authorities the hymen is simply formed from 
 the septum, which early divides the urogenital sini.o from the vagina. 
 The opening in it is produced by the involution of the epithelial cover- 
 ing of the urogenital sinus. 
 
 According to Hart (vide p. 36), the lower part of the vagina is 
 developed from the Wolffian duct. According to Nagel and others 
 [vide p. 36), it is of Mtillerian origin. The latter is most commonly 
 believed. 
 
 THE EXTERNAL GENITALS. 
 
 I 
 
 The external genitals occupy a triangular area in the pubic 
 region of the pelvis. They consist of mons veneris^ labia 
 majora^ labia mifiora^ clitoris^ vestibule^ foiirchette. 
 
 The mons veneris is the thick, fatty prominence, situ- 
 ated anterior to the pubes. It is covered with abundant 
 crisp, curly hair, the upper limit of which is a sharply 
 
THE LABIA MAJOR A. 
 
 41 
 
 defined transverse border. Occasionally the arrangement 
 of the hair, as it is found in males, is met with, namely, 
 (.xteiiding up towards the umbilicus in a triangular shape. 
 
 ihe labia majora are two thick folds of skin continuous 
 with the mens veneris (sometimes known as the anterior 
 commissure of the lal>ia\ ex- 
 tending backwards towards the 
 perineum. Usually they thin 
 out in their posterior parts, so 
 that they are not raised above 
 I the level of the surrounding 
 skin. The anterior margin of 
 [the perineum is called the 
 
 'posterior commissure of the 
 [labia ox fourchette. Sometimes 
 la distinct transversely curved 
 jridge is formed by the union. 
 On their outer surface they 
 
 ire covered with hair, which 
 
 rets scanty and short towards 
 
 the posterior ends. In the 
 
 skin are numerous sweat and 
 
 ^ebaceous glands. The sub- 
 cutaneous tissue consists of a 
 
 letwork of connective tissue, 
 
 r'ith abundant elastic fibres, 
 the meshes of which is a 
 
 irge quantity of fat. In the 
 
 deepest portion is a rich plexus 
 
 ^f veins communicating with 
 lose in the abdominal walls, with the vesical and vaginal, 
 
 nth the external haemorrhoidal, and with the obturator 
 
 ?eins. 
 The outer ends of the round ligaments blend with the 
 
 Issue of the upper portions of the labia. Sometimes the 
 
 persistent canal of Nuck extends into the upper end. 
 
 Fig. 20. — External genitals of 
 virgin. The labia are separated 
 artificially. The following parts 
 are seen : — 
 
 Mons veneris. 
 Clitoris. 
 Labium majus. 
 Labium minus. 
 Vestibule. 
 
 Urethral orifice. 
 Hymen. 
 Fourchette. 
 Anus. 
 
4i THE EXTERNAL GENITALS. 
 
 The labia minora, or nymphse, are two small folds 
 of skin internal to the upper parts of the labia majora, 
 one on each side. 'i'hey arc moist and of a reddish 
 tinge. Usually they do not project beyond the labia majora. 
 When they do, the outer portions become brown in colour. 
 Anteriorly, they approach the middle line, and each divides 
 into two parts. The upper of these blend to form a cover- 
 ing to the glans clitoridis — the prepuce. The lower blend 
 at a sharp angle under the glans to form the frenum or 
 suspensory ligament of the clitoris. Posteriorly, the labia 
 usually spread out gradually and are lost in the labia 
 majora about half-way down the latter. Sometimes they 
 extend backward as distinct structures, and form a well- 
 marked ridge on the anterior margin of the perineum. 
 (This condition is usually found in girls.) 
 
 The labia are covered with ordinary stratified squamous 
 epithelium. 
 
 In the erect posture the labia majora and minora lie 
 almost parallel to the horizon. The inner surfaces of the 
 former are in apposition, when well developed, and under 
 ordinary conditions. The latter are always in apposition 
 save when actually moved apart. 
 
 Sebaceous glands are present, especially near the anterior 
 ends. From these the smegma is formed, which is found 
 about the clitoris. I have also found sweat glands. There 
 are no mucous glands. 
 
 In the papillae of the skin, I have found the following 
 nerve endings : — 
 
 {a) Krause's end bulbs. — These are the most numerous in the 
 labia minora. They are found in the papillae of the skin and in the 
 deepest layers of the choriuni. They appear ovoid, oblong, and round 
 in different sections. 
 
 In and near the prepuce are compound globular endings, consisting 
 apparently of two single end bulbs bound together. Whether these 
 have any relation to the genital corpuscles found in the clitoris, it is 
 impossible to say. 
 
 {b) Pacini's or Vater's corpuscles. — These are few in number, 
 
 M 
 
 ( \ 
 
THE CLITORIS. 
 
 43 
 
 in number, 
 
 ami are found in the upper parts of the lahia, besides the well- 
 known single form, I have found doul)lc and triple forms. The 
 (|(>iil)lc corpuscle consists of two single Ixxlios, each of which has a 
 <inlral core surrounded by delicate concentric layers, lK)th being 
 tiivolopod in a common capsule made up of several concentric coats. 
 In a few instances I have found that the individual cf)rpusck's arc 
 yparato at one end, though bound together in a common sheath in 
 must of their length. In the triple cor- 
 
 uscl'j two are within a common capsule ; 
 
 ,,e third, a small one, Ix-'ing in the wall 
 of one of the larger ones. In some cor- 
 puscles a single axis cylinder, and in 
 others a double one is found. 
 
 (<) Wagfner-Meissner touch cor- 
 puscles. I have found a few scattered 
 ones. Krause denies their presence. 
 Those who have described large numbers 
 have probably mistaken the ovoid or 
 o'jlong sections of Krause's end bulbs 
 for them. Krause has referred to the 
 poorly developed sense of touch in the 
 labia minora. I have tested the tactile 
 [sense, and have found that the prepuce 
 is more sensitive than the labia minora, 
 and these more sensitive than the labia 
 niajora and mons veneris. By Weber's 
 test, the shortest distance at which two points can be distinctly re- 
 icognised is, on the prepuce, I cm. ; on the labia minora, 1.25 cm. ; on 
 [the labia majora, 4 cm. 
 
 (Carrard has described in hypertrophied nymphce an end organ like 
 llhlder's, found in certain birds. I believe this to be either a touch 
 ■corpuscle or an end bulb, pathologically altered. I have been unable 
 jto distinguish it in the normal nymphai.) 
 
 Note. — There are conflicting opinions as to the part played by the 
 labia minora in the produciion of the sexual sense. If Krause be right 
 in relating it to the special genital corpuscles first described by him, 
 
 then, probably, the nymphoe serve no special sexual function. I have 
 
 lot found Krause's genital corpuscles in the nymphte. 
 
 The clitoris. — The clitoris, corresponding to the male 
 Denis, is situated in front of the lower margin of the sym- 
 )hysis at the upper end of the labia minora. It consists 
 )f two crura, body and glans. 
 
 Fig. 21. — Double Pacini- 
 Vater corpuscle. 
 
44 
 
 THE EXTERNAL GENITALS. 
 
 The crura are two in number, one on each side. 
 Each is attached posteriorly to the bone formed by the 
 blended descending pubic and ascending ischial ramus. 
 Thence they run upwards, forwards, and inwards, and meet 
 under the subpubic ligament to form the body of the clitoris. 
 Each crus is covered with the ischio-cavernosus muscle. 
 
 The corpus clitoridis in the erect condition is about 
 f in. in length. It is not straight, but bent, so that a 
 sharp concavity is on its under surface. It is made up 
 of the two crura, consisting ot cavernous tissue, bound in 
 a fibrous capsule and with a septum between, which is 
 perforated in several places. The fibrous capsule is con- 
 tinuous on the anterior part of the under surface with the 
 frenum (suspensory ligament) by which the corpus is fast- 
 ened to the lower anterior part of the symphysis pubis. 
 
 The gliifis is a small acorn-shaped body, varying in 
 dimensions up to the size of a pea, and situated at the 
 anterior end of the corpus. It is not directly continuous 
 with it, but is connected by the pars intermedia of the 
 bulb. It corresponds to the glans penis in the male, but 
 is not perforated by the urethra. On its under surface is 
 a triangular space between the attachment of the two layers 
 of the frenum. It is made up of cavernous tissue, its outer 
 surface being covered with a thin layer of stratified squamous 
 epithelium. 
 
 The arteries of the clitoris are branches of the internal 
 pudic. They run in the crura and become the dorsal 
 arteries of the clitoris. The veins open into the pudic 
 plexus ; those of the glans open into the pars intermedia 
 of the bulb. 
 
 In the glans I have found the following nerve endings : — 
 
 1. Wagner- Meissuer corpuscles, very few in number. 
 
 2. Kratise's end bulbs. 
 
 3. Vater-Pacini corpuscles. — These are few in number, and are situ- 
 ated in each half of the posterior part of the glans, near the junction 
 with the prepuce. They are mostly compound. 
 
 4. Genital corpuscles of Krause. — These are found especially in two 
 
THE VESTIBULE. 
 
 45 
 
 groii|)s, one on each side of the middle Hne, especially abundant in the 
 anterior part. They are irregularly rounded or oblong, forming several 
 compartments, in which the terminal nerve-fibres lie. These vary in 
 shape considerably, according to the planes in which sections are 
 made. 
 
 The nerve endings in the prepuce have already been described. 
 
 Note. — The clitoris is capable of becoming erect and hard ; probably 
 the mechanism by which this is brought about is similar to that found 
 in the penis. 
 
 The ischio-cavernosui auscle (erector clitoridis) of ' ach 
 side is inserted into a fascia, which envelops tl e posterior 
 part of the corpus clitoridis. By this 
 arrangement, contraction of the muscles 
 can cause a constriction which leads to a 
 venous engorgement of the organ. 
 
 Development of the clitoris. — At first the 
 clitoris appears as a projection — the sexual em- 
 inence, at the anterior part of the urogenital 
 sinus. During the first two months no prepuce 
 can be distinguished. This takes place probably 
 about the third month, as Hart has described, as 
 follows : — 
 
 A thimble-like involution of the epidermis 
 occurs, the open base reaching what forms the 
 corona of the glans. The central epithelial cells 
 of the involution are less active, and desquamate, 
 whereby a slit is left between the glans and the 
 covL'»"ing prepuce. If a coronal section be made 
 through the sexual eminence at this stage, the epi- 
 thelial involution appears sickle-shaped. 
 
 The vestibule. — The vestibule is the smooth, red, trian- 
 gular surface, whose apex is formed by the frenum of the 
 clitoris, base by the hymen, and sides by the labia minora. 
 In the middle line at the base lies the external orifice of the 
 urethra. In the nullipara the slit of the urethral opening 
 is triradiate in shape ; on stretching the vestibule trans- 
 versely, the slit becomes transversely crescentic, the con- 
 cavity looking backwards. Between the orifice and the 
 I clitoris is sometimes seen a slightly raised ridge, called 
 
 I''iG. 22. — Geni- 
 tal corpuscle of 
 Krause. 
 
V 
 
 46 
 
 THE EXTERNAL GENITALS. 
 
 by Pozzi the " male vestibular band." It surrounds 
 the orifice of the urethra, and passes into the hymen. 
 Pozzi believes it to correspond to the anterior part 
 of the corpus spongiosum, which surrounds the male 
 urethra. 
 
 Several small depressions of various depths exist on each 
 side between the urethra and the nymphaj ; they are more 
 noticeable in multiparas. ' 
 
 Close to the hymen, behind the urethral orifice, a few 
 small mucous glands are found. 
 
 The corpus cavemosum urethrae. — This structure, com- 
 posed of erectile tissue, consists of a central and two lateral 
 portions. 
 
 The central portion, known as the pars intermedia^ lies in 
 front of the urethra, and anteriorly forms the connection 
 between the glans and corpus clitoridis. It rests internally 
 against the lower anterior margin of the symphysis, the 
 vestibule being external to it. The lateral portions, known 
 as the bulbs of the vagina, are elongated bean-like struc- 
 tures (3-5 cm. long, 1-5 cm. wide, i cm, thick), which lie, 
 one on each side of the introitus vagiticc^ in relation in- 
 ternally with the anterior layer of the triangular ligament in 
 the greater part of their extent ; at their posterior extremities 
 they partly cover the Bartholinian glands. 
 
 Considerable \ iations are found in the extent to which 
 the spongy body is develop:^d. Usuallv, the central portion 
 becomes relatively less pronounced a? the child grows older ; 
 generally, in adult life, it is not visible as a projection in the 
 middle line of the vestibule. It varies also in the region of 
 the urethral orifice and hymen. It surrounds the urethra, 
 and may occasionally project somewhat into the hymen, 
 making this structure very vascular. 
 
 The corpus cavemosum is erectile tissue, and is composed 
 of tortuous anastomosing blood vessels in a framework of 
 thin connective tissue. On section, it has a spongy appear- 
 ance. Blood enters the bulbs at their posterior ends from 
 
 # 
 
 \ \ 
 
THE BARTHOLINIAN GLANDS. 
 
 47 
 
 )ranches of the pudic arteries, while the pars intermedia 
 jommuiiicates with the arteries of the ditoris. The outlet 
 ireins are mainly at the posterior ends of the bulbs, com- 
 
 lunicating with the pudendal veins, the inferior hremor- 
 rhoidal and the vaginal plexus ; the anterior parts of the 
 )ulbs and the pars intermedia join the veins lying under 
 the vestibule. 
 
 Under sexual excitement, the corpus cavernosum enlarges 
 )uing to congestion of its vessels. Thic is brought about, 
 jartly, by the constriction of the clitoris, caused by the 
 :ontraction of the ischio-cavernosus muscles, partly by the 
 :ontraction of the bulbo-cavernosus (sphincter vagin?e). 
 iThese latter cover the bulbs as they extend from the 
 )erineum forwards, to end in a fascia which embraces 
 the corpus clitoridis. 
 
 The Bartholinian glands. — These structures, correspond- 
 ing to Cowper's glands in the male, vary in size from a pea 
 ^o a bean, and lie one on each side of the vaginal orifice, 
 )artly under cover of the posterior end of the bulb of the 
 /agina, partly under the bulbo-cavernosus (sphincter vaginae) 
 
 uiscle. In some cases they are entirely covered by the 
 
 itter muscle. Sometimes they are partly embedded in the 
 kpongy tissue of the bulbs. Internally, they are in relation 
 \o the triangular ligament. 
 
 Each gland consists of a large number of divisions lying 
 |n a connective tissue framework, containing some smooth 
 nuscle fibres. Each division, lined with goblet-like mucus 
 secreting cells, communicates with the main duct of the 
 ^land, which extends from the inner anterior margin for- 
 ft'ards to the posterior angle of the vestibule, where it 
 )pens on the inner margin of the labium minus close to the 
 
 lymen. In the multipara the opening may be hard to find 
 )wing to the irregularities of the caruncules myrtiformes. 
 
 'he outer part of the wall of the duct consists of connective 
 tissue with some non-striped muscle. 
 It is lined in the great part of its extent with cylindrical 
 
f 
 
 
 48 
 
 THE EXTERNAL GENITALS. 
 
 epithelium ; at the outer end with stratified squamous 
 epithelium. 
 
 Sometimes the gland is not a single mass, but consists of 
 several separate portions. Sometimes it is entirely absent 
 on one or both sides. Rarely, there may be two ducts on 
 one side. 
 
 Fig. 23. — Internal genitals in new-born child. — After Nagei. 
 
 I. 
 
 Uterine artery. 
 
 7- 
 
 Ovary. 
 
 14. Bladder. 
 
 2. 
 
 Ureter. 
 
 8. 
 
 Uterus. 
 
 15. Umbilical artery. 
 
 3- 
 
 Ovarian artery. 
 
 9- 
 
 Ilio-inguinal 
 
 16. External iliac 
 
 5- 
 
 Fallopian tube. 
 
 
 nerve. 
 
 artery. 
 
 6. 
 
 Round ligament. 
 
 12. 
 
 Rectum. 
 
 
 Note. — The secretion is clear, glairy mucus, and serves as a lubricator 
 of the vestibule and adjacent parts. During sexual excitement it may 
 be expelled suddenly, by the muscular fibres in the gland stroma, as 
 well as by the overlying bulbo-cavernosus muscle. 
 
 Development. — The Bartholinian glands are formed from a buddini; 
 inwards of the epithelium of the urogenital sinus. By the time the 
 uterus and vagina are distinct from one another, it is quite formed, 
 though of small size. Mucus is secreted at an early age. 
 
 k 
 
 
 W 
 
THE OVARIAN ARTERIES. 
 
 49 
 
 )ut consists of 
 
 ;ntirely absent 
 
 two ducts on 
 
 ^r Nagel. 
 
 and stroma, as 
 
 from a budding 
 y the time the 
 quite formed, 
 
 BLOOD VESSELS, LYMPHATICS, NERVES. 
 
 Arteries. 
 
 The ovarian arteries (named "spermatic" in the 
 lale) sometimes arise from the aorta, close to the renal 
 
 Fig. 24. — Dissection of pelvis from above. — From Nagel. 
 
 1. Uterine artery. 
 
 2. Uterine vein. 
 
 3. Obturator nerve. 
 Umbilical arterj'. 
 Obturator artery. 
 Viiginal artery. 
 Ureter. 
 
 8. Vesical artery. 
 
 9. Vesico-vaginal 
 
 vein, 
 o. Uterus. 
 
 11. Utero-sacral 
 
 ligaments. 
 
 12. Ovary. 
 
 13. Tube. 
 
 14. Rectum. 
 
 15. Bladder. 
 
 16. Levator ani. 
 
 17. Common iliac 
 
 artery. 
 
 18. External iliac 
 
 artery. 
 
 19. 
 
 21. 
 
 22. 
 23. 
 24. 
 
 25. 
 
 Hypogastric 
 
 artery. 
 Hypogastric 
 
 vein. 
 External iliac 
 
 vein. 
 Ovarian artery. 
 Ovarian vein. 
 Psoa.s muscle. 
 Broad ligament. 
 
 ^teries. Usually, however, the left alone has this origin, 
 \t right artery arising from the right renal. Each extends 
 4 
 
V 
 
 so 
 
 BLOOD VESSELS, NERVES, ETC. 
 
 down the back wall of the abdomen, behind the peritoneum, 
 on the inner aspect of the psoas, close to the inferior vena 
 cava for a distance. 
 
 It crosses the ureter, enters the upper part of the in- 
 fundibulo-pelvic border of the broad ligament, and runs 
 tortuously through the latter, below the ovary, towards the 
 upper lateral angle of the uterus, where it anastomoses 
 with the uterine artery. Tortuous branches are given off 
 to the ovary, and others, not so tortuous, to the Fallopian 
 tube. 
 
 The explanation of the great length of these arteries is the distance 
 through which the ovaries move. In early life they are near the kid- 
 neys. Afterwards they descend into the pelvis, their vessels elongating 
 accordingly. 
 
 The uterine arteries. — These arise from the anterior 
 divisions of the internal iliacs. Each passes downwards 
 and inwards through the broad ligament, towards the 
 cervix, near which it passes in front of the ureter. When 
 it crosses the latter it divides into two branches. One of 
 these breaks up into small twigs and supplies the cervix, 
 sending divisions down the upper part of the vaginal 
 walls. 
 
 The other and larger branch winds tortuously up the side 
 of the corpus uteri as far as the Fallopian tube, where it 
 divides into two parts, the upper of which runs along the 
 whole length of the tube, the lower anastomosing with the 
 ovarian artery ; in this way a considerable arterial network 
 is formed in the broad ligament near the angle of the 
 uterus. 
 
 The branches to the uterus run under the peritoneum 
 tortuously. An anastomosis takes place between the vessels 
 of opposite sides. At the isthmus a circular artery is 
 in this way formed ; from it the azygos vagince artery runs 
 downwards. The twigs which penetrate the muscular part 
 of the wall run more or less at right angles to the long axis 
 of the uterus. 
 
 \\ 
 
THE VAGINAL ARTERIES. 
 
 51 
 
 ; peritoneum, 
 inferior vena 
 
 is the distance 
 re near the kid- 
 ssels elongating 
 
 The vaginal arteries. — As a rule, these arise from the 
 anterior division of the internal iliac. Sometimes they 
 si)ring from the uterine or middle haemorrhoidal. They run 
 downwards and inwards to the sides of the vagina, dividing 
 
 Fig. 25. — Dissection showing vessels of pelvis. — From Nag'cl. 
 
 I. 
 
 Uterine artery. 
 
 8. 
 
 Obturator artery. 
 
 14- 
 
 External iliac 
 
 2. 
 
 Ureter. 
 
 9- 
 
 Umbilical artery. 
 
 
 vein. 
 
 3- 
 
 Uterine vein. 
 
 10. 
 
 Hypogastric 
 
 16. 
 
 Uterus. 
 
 4- 
 
 Obturator vein. 
 
 
 vein. 
 
 17- 
 
 Cervix and va- 
 
 5- 
 
 Vesico-vaginal 
 
 II. 
 
 Internal pudic 
 
 
 ginal fornix 
 
 
 vein. 
 
 
 vein. 
 
 
 moved aside. 
 
 6. 
 
 Utero-vaginal 
 vein. 
 
 12. 
 
 Hypogastric 
 artery. 
 
 18. 
 
 Vagina. 
 
 7- 
 
 Internal pudic 
 vein. 
 
 13. 
 
 External iliac 
 artery. 
 
 
 
 linto several branches. Those of one side anastomose 
 freely with those of the other, and with an azygos artery 
 
 jwhich runs down the middle of the anterior vaginal wall 
 from the circular artery of the cervix. 
 Branches are given to the bladder and lower part of the 
 
 Irectum. 
 
V 
 
 52 
 
 BLOOD VESSELS, NERVES, ETC. 
 
 Vesical arteries. — The superior vesical are two or three 
 twigs which spring from the pervious part of the obliterated 
 hypogastric artery. They supply the upper part of the 
 bladder, and give a branch to the urachus. 
 
 The inferior vesical is derived from the anterior division 
 of the internal iliac, and supplies the lower portion of the 
 bladder. 
 
 P'iG. 26, — Dissection showing arterial branches in broad 
 ligament of multipara. — From Nagel. 
 
 1. Right uterine 
 
 artery. 
 
 2. Cervico-vaginal 
 
 artery. 
 
 3. Azygos vaginae 
 
 artery. 
 
 4. Right ovarian 
 
 artery. 
 
 6. Uterus 
 
 7. Vagina. 
 
 8. Round ligament, 
 g. Fallopian tube. 
 
 The middle hsemorrhoidal arteries. — These vessels 
 generally spring from the inferior vesical ; sometimes, from 
 the internal pudic. They ramify on the lower part of the 
 rectum, anastomosing with twigs from the other hsemor- 
 rhoidal vessels and with the inferior vesical. 
 
 The internal pudic arteries. — Each of these forms 
 one of the terminal branches of the anterior division 
 of the internal iliac. After the vessel passes out of the 
 
 Jv 
 
THE ARTERIES. 
 
 53 
 
 pelvis, it gives off the inferior or external hemorrhoidal 
 artery, supplying the region of the anus ; the superficial 
 
 \ perineal artery, supplying the labia; the transverse perineal \ 
 the arteries of the vaginal bulb ; the deep arteries of the 
 clitoris going to its body ; the dorsal artery of the clitoris 
 going to the glans. The inferior twigs of the external 
 
 \pudic branches of the femoral artery give some supply 
 to the labia. A twig from the deep epigastric branch 
 of the external iliac runs in the round ligament. 
 
 Fig. 27. — Left half of pelvis of new-born child. — From Nagei, 
 
 1. Uterine artery. 
 
 2. Ureter. 
 
 6. Internal pudic 
 
 artery. 
 
 7. Vesico-vaginal 
 
 artery. 
 
 10. Umbilical 
 
 artery. 
 
 11. External iliac 
 
 artery. 
 
 12. External iliac 
 
 vein. 
 
 13. Uterus turned 
 
 down. 
 
 14. Bladder. 
 16. Vagina. 
 
 Veins. 
 
 The veins of the pelvis form a larg*. network. They 
 possess as a rule no valves. To different parts of the 
 
54 
 
 BLOOD VESSELS, /SERVES, ETC. 
 
 network special names are given : — The uterine plexus, 
 surrounding the uterus ; the ovarian or pampiniform 
 plexus, in the broad ligament ; the vaginal plexus, one 
 outside the muscular coat, and one in the submucous 
 tissue ; the vesical plexus ; the hsemorrhoidal plexus, 
 outside the mucosa of the lower part of the rectum. 
 
 From these plexuses blood is carried into the main 
 venous trunk by the ovarian, uterine, vaginal, and vesical 
 veins. The haemorrhoidal plexus is also drained by the 
 superior hcemorrhoidal vein which enters the portal circu- 
 lation. There is thus a communication between the pelvic 
 and portal venous systems. 
 
 At the upper end of each ovarian vein there is usually 
 a valve. This is often absent in the left side, when in 
 place of it there is one in the left renal vein near the 
 junction. 
 
 The veins of the labia correspond to the arteries. Those 
 of the labia minora communicate with the pars intermedia 
 of the bulb. The veins of the clitoris communicate with 
 the vesical plexus by means of the dorsal vein. The veins 
 of the bulb join the vaginal plexus. 
 
 Lymphatics. 
 
 The inguinal glands, external to Poupart's ligament, 
 receive the lymphatic vessels of the vulva, lower fourth of 
 the vagina, and lower part of the urethra. 
 
 The hypogastric or internal iliac glands, lying sub-peri- 
 toneally between the external and internal iliac vessels, 
 receive the vessels of the bladder, upper part of the 
 urethra, upper three-fourths of the vagina and cervix 
 uteri. 
 
 The sacral glands, lying on the anterior wall of the 
 sacrum and in the mesorectum, receive the vessels from 
 the rectum. 
 
 The lumbar glands (median group), lying along the 
 
THE LYMPHATICS, 
 
 55 
 
 common iliac vessels, the aorta and vena cava, receive 
 lymphatics from the glands within the pelvis. 
 
 The glands of Guerin in the obturator foramen com- 
 municate both with the lymphatics of bladder, vagina, and 
 cervix, and with external lymphatics in the inguinal region. 
 
 The uterine lymphatic system, by means of the round 
 ligaments, communicates with the inguinal vessels. 
 
 I'IG. 28. — Post-partum uterus with injected arteries. — From Nagel. 
 
 0. Ovary. 
 
 t. Fallopian tube. 
 
 II. Left ovarian artery. 
 18. Right ovarian artery. 
 
 An arrow is placed below the os externum. 
 
 Nerves. 
 
 The uterus is supplied both by the spinal and sympathetic 
 nerves. The latter are derived from the hypogastric plexus, 
 which lies between the common iliac arteries. It is a con- 
 tinuation of the aortic and renal plexuses. It extends down- 
 
I 
 
 I 
 
 $6 
 
 BLOOD VESSELS, NERVES, ETC. 
 
 wards in two main branches, one on each side of the 
 rectum. These are joined by twigs, especially from the 
 third and fourth sacral, and also by branches from the 
 sacral sympathetic ganglia. 
 
 From each of the pelvic plexuses is derived a vaginal, 
 haemorrhoidal, and a vesical plexus. The part which passes 
 in towards the cervix joins the cervical ganglion, situated 
 on each side, close to the vaginal roof. This ganglion was 
 discovered by Robert Lee. 
 
 For a long time there was a dispute as to this ganglion, Sharpey being 
 prominent in denying its existence. 
 
 This ganglion is surrounded by a dense plexus (utero- 
 vaginal), and is connected with a vesical plexus, in which a 
 ganglion is also situated. 
 
 The nerves of the uterus arise mainly out of these three 
 ganglion plexuses, especially from the cervical. 
 
 Recently it has \ieen suggested that the cervical ganglion plays an 
 important role in connection with labour, pressure on it as the cervix 
 expands leading to the continuance of the process. 
 
 A few nerves go directly to the uterus from the hypo- 
 gastric plexus. 
 
 The ovaries are supplied from the renal plexus, and 
 from the aortic plexus of sympathetic nerves. Usually 
 there is an ovarian (spermatic) ganglion on each side of the 
 aorta, near its lower end. The ovarian plexus accompanies 
 the artery, and gives branches to the ovary and tube, and 
 communicates with the uterine nerves, a ganglion being 
 formed near the uterus. 
 
 The Fallopian tubes are supplied by branches of the 
 uterine plexus as well as by the ovarian. The vagina is 
 supplied by the cervical and vesical ganglia and by branches 
 from the third and fourth sacral nerves. 
 
 As regards the finer ramifications in the uterus and 
 vagina, there is a dense network in the muscular part of 
 the wall and in the mucosa, containing many ganglion cells. 
 End organs are found close to the epithelial layer. 
 
 i\ 
 
THE NERVES, 
 
 57 
 
 ion plays an 
 IS the cervix 
 
 The externa! genitals are supplied by sympathetic nerves 
 running with the arteries, and by twigs of the genito- 
 crural branch of the lumbar plexus, as well as by those 
 from the inferior pudendal and internal pudic branches of 
 the sacral plexus. The clitoris is supplied by twigs from 
 the latter nerve. 
 
 KiG. 29. — Nerves of right side of uterus, bladder, vagina, and rectum. 
 — From Fkankenhausek. 
 
 I. Cervical gan- 
 
 3. Second and third 
 
 5- 
 
 Ureter. 
 
 glion. 
 
 sacral nerves. 
 
 6. 
 
 Uiadder. 
 
 2. Fourth sacral 
 
 4. Hypogastric 
 
 7- 
 
 Uterus. 
 
 nerve. 
 
 plexus. 
 
 8. 
 
 Rectum. 
 
 THE BLADDER. 
 
 The empty bladder normally lies below the level of the 
 pelvic brim, behind the pubes. 
 In this state, when relaxed, the upper surface is concave. 
 
T 
 
 ! ' . 
 
 58 
 
 THE BLADDER. 
 
 On vertical mesial section the slit of the cavity forms 
 with the urethra a Y-shape, the anterior limb being longer 
 than the posterior. The bladder may now be described as 
 having an upper surface ; an anterior^ in relation to the 
 pubes ; and a posterior^ in relation to the vagina. 
 
 When empty and contracted, the bladder, on vertical 
 mesial section, is oval in shape, its walls are thick, and its 
 mucosa wrinkled. The slit of the cavity is a single curved 
 one, its concavity looking forwards. 
 
 When moderately filled, the bladder is rounded on vortical 
 mesial section, its upper surface being somewhat above the 
 
 brim level. In this state the 
 widest diameter is the trans- 
 verse. (In man this is the 
 narrowest.) 
 
 When distended, it becomes i 
 egg-shaped, the lowest part 
 being the large end. Its long 
 axis vari.^is according to the 
 degree of distension, as well 
 as according to the condition 
 of neighbouring viscera. In 
 the distended condition the 
 longest axis is usually the 
 vertical. 
 
 Distension may take place until the fundus reaches 
 the umbilicus. In this state it sinks somewhat in the 
 pelvis, unless prevented by some special pelvic condition. 
 
 The female bladder, according to Luschka and Henle, is naturally of 
 smaller capacity than that of the male. Usually the female is thought 
 to be greater. 
 
 The superior surface is covered with peritoneum, and is 
 in relation to ♦ihe uterus. The reflections of the peritoneum 
 from the bladder form folds known as the false ligaments. 
 There are two behind, the utero-vesical ; two laterally, the 
 lateral ; one in front, the superior, which passes from the 
 
 Fig. 30. — Section showing the 
 shape of the bladder when 
 empty and contracted. 
 
STRUCTURE. 
 
 59 
 
 apex of the bladder. The summit is connected to the 
 abdominal wall by a mesial cord, the urachus — the remains 
 of the stalk of the allantois. 
 
 When the bladder becomes over-distended, it rises faster than it 
 strips •' e peritoneum Irom the anterior wall. In this way a pouch 
 forms between the bladder and the wall. In the ^Veal^b.* distension, 
 the peritoneum is stripped from the wall above the pubes for about 2 in. 
 
 The lateral limit of the superior surface is formed by 
 the obliterated cord of the hypogastric artery, which is con- 
 nected with the superior vesical artery, and runs forwards 
 and upwards to the umbilicus. Below this cord the bladder 
 is in relation to paravesical connective tissue. 
 
 The anterior surface is normally in relation to the pubes. 
 Occasionally its upper end rests just above the bone. The 
 loose areolar tissue between the bladder and the symphysis 
 is sometimes called the space of Retzius. 
 
 The posterior surface is in relation to the cervix uteri 
 and the upper part of the vagina. There is loose cellular 
 tissue between them. This surface is also called the base 
 of the bladder. 
 
 The bladder is generally situated mesially, but it is often found 
 slig' tly more to one side than the other. 
 
 In the erect position the opening of the urethra is the lowest part of 
 the bladder. 
 
 Structure. — The peritoneal covering of the upper wall 
 has been referred to. The muscular part of the wall is 
 made up of an outer more or less longitudinal layer ; a 
 middle, thin, irregularly reticulated layer ; and an inner, 
 longitudinal coat. 
 
 The mucous membrane is pale pink in colour, soft, 
 and rugose, save when the bladder is distended. It is 
 loosely attached '^o the muscular part of t'- - wall, except 
 at the trigone. It is lined with strati transitional 
 epithelium, like that of the ureter, the cells varying in 
 appearance according to the state of the bladder ; in the 
 distended nn<iltion they are more flattened out. The 
 
n 
 
 
 ii 
 
 
 w 
 
 V 
 
 60 
 
 THE URETHRA. 
 
 rugosities of the wall of the empty bladder are due to the 
 wrinkling of the mucosa and also to the ridges formed by 
 iinderlying muscular fasciculi. 
 
 At the internal urethral orifice the mucosa is corrugated 
 longitudinally. (This part of the bladder is called the 
 neck.) Immediately behind it is the trigone, a triangular 
 surface bounded by imaginary lines joining urethral and 
 ureteral orifices. The mucosa of this area is smooth, being 
 connected to the muscular coat by dense, firm connective 
 tissue. In the non-contracted state, t«he sides of the trigone 
 are about if in. in length. 
 
 The ureteral orifices are oval slits, and are directed for- 
 wards and inwards. 
 
 Between them the bladder mucosa is raised in a curved 
 ridge, the convexity looking forwards. It is due to a sub- 
 mucous muscular band, which joins the ureters and binds 
 them to the bladder. The ridge usually runs outwards and 
 backwards from the ureteral orifices for a short distance. 
 From the middle of this ridge a slight elevation projects 
 forwards towards the urethral orifice, the uvula vesica. 
 
 Note. — In infancy the chief part of the bladder lies above the 
 symphysis. It gradually sinks as the child grows, partly owing to its 
 weight, to the erect position of the body, and to the increasing width of 
 the pelvis. In a child of 6, Symington found the bladder still partly 
 abdominal. 
 
 THE URETHRA. 
 
 The urethra is about i| in. in length, and is directed 
 from the bladder downwards and forwards parallel to the 
 vagina, sometimes with a slight sigmoid curve. Its anterior 
 and posterior walls are in apposition, save during micturition. 
 The width of the closed tube is about \ in. The external 
 orifice is a vertical slit, with slightly projecting ridges, 
 situated in the middle line at the base of the vestibule. 
 
 The muscular part of the w^all consists of smooth and 
 striped layers. 
 
 ( » 
 
THE URETHRA. 
 
 6i 
 
 The smooth muscle is arranged in an outer circular and 
 in an inner longitudinal layer, separated by a considerable 
 amount of connective and elastic tissue. There is a rich 
 vascular arrangement, so abundant that some have given the 
 name of corpus spongiosum urethne to the non-striped layers. 
 
 The striped muscle lies external to the smooth layer, but 
 is not evenly distributed. It is mainly in a circular bundle — 
 internal sphincter, around the upper end of the urethra. A 
 similar arrangement exists at the lower end ; it is embraced 
 by the anterior fibres of the sphincter vaginae, from which it 
 may be derived. 
 
 The mucosa is raised in longitudinal folds, one being 
 especiaHy marked mesially on the posterior wall, the so- 
 called crista urethralis. The epithelial lining in the upper 
 part is like the transitional epithelium of the bladder. 
 Towards the lower portion the most superficial cells are 
 somewhat flattened. Under the epithelium is white con- 
 lective tissue and elastic fibres. 
 
 On the mucosal surface are numerous lacunse and also 
 acinous mucous glands, especially numerous at the upper 
 part of the urethra. They often contain, in old people, 
 small brownish masses, like prostatic calculi in men. 
 
 Very often two small blind glandular ducts are found in 
 the posterior wall, opening at the external orifice. Some- 
 times they are mere crypts, sometimes they may be \ in. to 
 I in. in length. 
 
 There is a discussion as to the nature of these. According to Nagel, 
 they have long been known as the para-urethral ducts, or as the ducts of 
 Malpighi. More recently they have been known as the ducts of Skene. 
 By some they are considered to be the remains of the lower ends of 
 Gartner's canals. 
 
 Nagel denies this origin, and says that they are formed in early 
 embryonic life as a depression of the epithelium covering the urogenital 
 sinus, at a time when Gartner's canals have disappeared from every part 
 save the broad ligaments. 
 
 Note. — The urethra is very distensible, all the folds being flattened 
 out, save ♦^he mesial one of the posterior wall. 
 
V 
 
 
 62 THE URETERS. 
 
 THE URETERS. '^ ' 
 
 The ureters extend from the sinus of the kidney to the 
 bladder. Their upper ends are enlarged to form the pelvis 
 of the kidney. From the lower end of the gland down- 
 wards the ureter is a simple cylindrical duct. The whole 
 length varies from 14 to 16 in. It runs downwards and 
 inwards on the psoas muscle, under the peritoneum, to- 
 wards the brim of the pelvis. 
 The right ureter lies close 
 to the inferior vena cava, 
 and sometimes gets in front 
 of it. At the brim it lies in 
 the hollow on each side of 
 the promontory. It crosses 
 the external iliac vessels and 
 lies in the space between 
 them and the internal iliac, 
 and is directed downwards 
 and forwards, lying against 
 the pelvic wall, covered by 
 Fig. 31.— Diagram showing relation the peritoneum continuous 
 of ureters to cervix, vagina, and ^j^j^ ^^^ posterior layer of 
 bladder. ^. •' 
 
 the broad ligament. At the 
 level where the uterine artery begins to curve inwards, the 
 ureter leaves the pelvic wall. 
 
 Here the uterine artery, which has in its upper part 
 passed external to the ureter, now arches in front of it, 
 being separated from it by a space f in. wide, filled with a 
 venous plexus. The ureter curves in towards the cervix, 
 approaching to within 4 of an in. (0.8 to 2 cm. is the range 
 of variation) from its lower portion. It then passes in front 
 of the uterus towards the base of the bladder. Opposite 
 the lateral fornix it is separated from the vagina by a 
 distance of /g- in. (i cm.), being surrounded by richly 
 vascular tissue. 
 
 r\ 
 
DEVELOPMENT OF EXTERNAL GENITALS. 63 
 
 From a point opposite the lower part of the cervix 
 it extends forwards and downwards between the vagina 
 and posterior wall of the bladder for about i in. (2^ 
 cm.), when it enters the bladder base, and runs through 
 
 Fig. 32. — Development of 
 the external genitals. 
 
 The Miillerian tract is shown 
 communicating with the 
 allantois and the latter with 
 the rectum. The beginning 
 of the vulva is seen as a 
 small depression of the skin. 
 
 Fig. 33. — Development of 
 the external genitals. 
 
 The median depression has 
 sunk inwards, so as to com- 
 municate with allantois 
 and rectum forming the 
 cloaca. 
 
 m ^ 
 
 Fig. 34. — Develop- 
 ment of the ex- 
 ternal genitals. 
 
 The perineal septum 
 is shown, dividing 
 the cloaca so as to 
 form the urogenital 
 canal and the anus. 
 The vagina and 
 bladder communi- 
 cate with the uro- 
 genital sinus. 
 
 Fig. 35. — Develop- 
 ment of the ex- 
 ternal genitals. 
 
 The perineum is 
 shown completely 
 formed. 
 
 Fig. 36.— Develop- 
 ment of the ex- 
 ternal genitals. 
 
 The urethro -vaginal 
 septum is shown, 
 the urethra and 
 vagina opening 
 into the vestibule 
 (lower part of the 
 urogenital sinus). 
 
 Figs. 32-36 are from Schroeder. 
 
 its wall, obliquely forwards and inwards for about \ in. 
 (1.3 cm.). 
 
 The distance between the ureters, opposite their point of 
 crossing of the cervix, varies from 2\\ to 3i\ in. (7.5 cm. 
 to 9 cm.) ; between their points of entrance into the 
 
V 
 
 64 
 
 THE URETERS. 
 
 
 bladder, \-^^ in. (4 cm.); between the points of junction 
 the bladder cavity — in the empty condition, i in. (2.5 
 
 with 
 
 ;in.), and, filled, if to 2 in. (4-5 cm.). 
 
 Note. — The connection between the ureter and the vaginal wall and 
 between the cervix and bladder varies in different cases. Usually it is 
 a loose one. If it be more or less firm, there will be increased danger 
 of wounding the ureters, or of tying them in the operation of vaginal 
 extirpation of the uterus, because they will be dragged down consider- 
 ably as the cervix is pulled on. It is important, before applying the 
 ligatures to the broad ligaments, to free the bladder from its con- 
 nections with the cervix, and to apply the lower ones close to the 
 cervix. 
 
 Development of the urinary tract and outer genitals.— 
 Nagel's description may be taken. The allantois begins as a hollow 
 extension of the posterior end of the primitive gut. 
 
 In the young human embryo (8 to 12 mm. in length) it appears 
 as a curved canal extending from the cloaca to the navel, completely 
 separated below from the gut. It is lined with low cubical epithelium. 
 The Wolffian ducts open into its posterior wall. 
 
 That part of the allantois below the Wolffian ducts forms the uro- 
 genital canal. The upper part narrows towards the navel and gets 
 gradually solid. At this period the Miillerian tracts are in a very 
 early stage, and are not to be found in the region of the lower ends 
 of the Wolffian ducts. On each side the ureter is found opening into 
 the Wolffian duct, from which they arise as outgrowths. The junction 
 of these two tubes forms a funnel-shaped passage, larger than either 
 of its component parts, opening into the allantois. 
 
 From this level the Wolffian ducts pass upwards and outwards to the 
 Wolffian bodies ; the shorter ureters pass upwards behind, and external 
 to them. Gradually, the ureter and Wolffian ducts become distinctly 
 separated at their lower ends, opening separately into the allantoic 
 canal, the ureters being external. This occurs before the Miillerian 
 ducts have reached the urogenital canal. 
 
 Then begins the formation of the bladder. The part of the allantois 
 immediately above the ureters forms a short spindle-shaped dilatation. 
 This is found, in embryos, 2.4 cm. in length. It is lined with cubical 
 epithelium, which becomes arranged in several layers. 
 
 From the remains of the allantois above the bladder is formed the 
 urachus. As the bladder increases in size, the ureteric orifices are 
 raised somewhat. 
 
 In the earliest human embryos observed, both Wolffian ducts and the 
 gut open -nto the lower part of the allantois at about the same level. 
 
 f^ 
 
DEVELOPMENT OF THE URINARY TRACT. 65 
 
 At this period the anus is closed liy the anal membrane, hut it soon 
 Ijccomes perforated. Then, through increase of the septum lying 
 between the Wolffian ducts and the gut, the lower part of the allan- 
 tf)is (endodermal cloaca) is divided into two parts, of which the former 
 gives rise to the urogenital sinus and the latter to the anus, both com- 
 municating with the ectodermal depression on a lower level — the true 
 cloaca. 
 
 If, after separation of the ureters from the Wolffian ducts, the outer 
 surface of the embryo be studied, the cloaca is seen as an antero- 
 posterior depression, into the posterior part of which the gut opens, and 
 into the anterior part the urogenital canal, a septum existing between 
 tlieni. It is covered with stratified epithelium. 
 
 The Wolffian ducts do not open into the cloaca, it must be under- 
 stood, but into the upper part of the urogenital sinus. 
 
 The antero-posterior extent of the cloaca corresponds to the adult 
 limit between the frenum of the clitoris and the posterior anal wall in 
 the female (between the anterior wall of the urethra and the posterior 
 anal wall in the male). 
 
 In both sexes the sides of the anterior part of the cloaca first become 
 blended. Gradually, also, bridges of epithelium extend across the 
 cloaca so as to leave openings communicating with the passages 
 above. 
 
 At the anterior end of the united cloaca is found a lozenge-shaped 
 area, siiuated at the base of the glans, in both sexes ; this disappears 
 in males, but remains in females. 
 
 In the meanwhile the Miillerian ducts have been extending down- 
 wards to the urogenital canal. This is reached in the embryo of 2. 5 to 
 3 cm. in length. When communication is established between them, 
 four canals, in all, open into the urogenital canal, namely, the two 
 Wolffian and the two Mullerian, the latter being internal to the former, 
 but at the same level. On the posterior wall of the canal where they 
 open, a small projection is found, known as Muller's eminence. Both 
 the Wolffian and Miillerian ducts are surrounded by a common mass 
 of tissue, thus forming the so-called genital cord. 
 
 Henceforth the course of development differs in males and females. 
 In the female, the Wolffian duct disappears save in the broad ligament, 
 where it forms the organ of Rosenmiiller and other remains. In 
 embryos of 4 cm. and upwards only the Miillerian ducts are found 
 opening into the urogenital canal. The latter and the gut, only, open 
 into the cloaca at this time. 
 
 Through the development of the vagina from the lowest end of the 
 blended Miillerian ducts, through the simultaneous shortening of the 
 canal to form the urogenital sinus, and through the 
 
 5 
 
 urogenital 
 
66 
 
 THE URETERS. 
 
 f 
 
 
 V 
 
 flattening of the latter to form the vestibule, the vaginal orifice is 
 brought to the pelvic floor. 
 
 Along with the development of the vagina goes that of the urethro- 
 vaginal septum and the urethra. 
 
 Posteriorly, the perineum develops through union of both sides of the 
 cloaca, taking place by means of an epithelial proliferation. 
 
 As regards the Wolffian ducts Nagel points out that at the beginning 
 of the development of the vagina they begin to shrink, and that there- 
 after, as a rule, remnants are not found below the level of the junction 
 of the uterus and the vagina. He does not believe that they are found 
 in adult life as low down as the urethral orifice. Before the vagina is 
 
 much developed, or the 
 Wolffian ducts degener- 
 ated, the latter open into 
 the urogenital sinus close 
 to the an/age of the 
 bladder. 
 
 If the ducts persist 
 they are more likely to ■ 
 be found in the anterior 
 vaginal wall, opening at 
 each side of the vaginal 
 entrance, rather than in 
 relation to the urethra ; but no such occurrence has yet been clearly 
 demonstrated. 
 
 Van Acheren has described a four-month embryo, in which small canals 
 were found in the lower part of the vagina. They could not, however, 
 be traced to the remains of the Wolffian duct in the broad ligament, 
 and there is no proof that they were of W^olffian origin ; Nagel regards 
 them as the anlagc of the Bartholinian gland. 
 
 G. Klein states that he found in a girl two ducts in the lower part of 
 the vagina leading into the hymen, the lower end of one being slightly 
 distended. 
 
 Koeberle has described two interesting cases, in which the relations 
 of persistent Wolffian ducts were clearly made out. In one of these 
 there was a development of one horn of the uterus only, the other being 
 rudimentary and imperforate. A persistent Wolffian duct ((Partner's 
 canal) extended from the longitudinal tube of the organ of Rosenmiiller, 
 through the broad ligament, and obliquely down through the wall of 
 the right cornu, entering it near the round ligament, and opening into 
 the cavity of the uterus at the os internum. 
 
 In the other case there existed a uterus bipartitus and a vagina septa. 
 The left half of the vagina was narrower than the right, and ended 
 
 Fig. 37,— Diagram illustrating the persistent 
 Wolffian duct in Koiberl^'s case. 
 
 n 
 
DF.VELOPMENT OF THE URINARY TRACT. 
 
 67 
 
 about half-way down the latter, communicating with it by a small 
 aperture. Opening into the left half of the vagina on its outer side 
 was a small canal which extended upwards into the uterine wall — the 
 remains of the Wolffian duct. 
 
 Dohrn has examined many specimens, but has never found traces of 
 the duct much below the level of the vaginal fornix. Rieder has found 
 remains in relation to the upper part of the vagina, but never near its 
 lower end. 
 
 Nagel is inclined to believe that the condition of double ureter has 
 been described by several writers as that of persistent Wolffian duct. 
 
 It is, indeed, not difficult to understand 
 why Wolffian remains should rarely be 
 found below the cervix. After the forma- 
 tion of the ureters, the ducts get cut off" 
 from the urogenital sinus, and, as the 
 latter becomes shallower, its wall moves 
 farther away from the ducts. At the 
 same time, owing to the vertical develop- 
 ment and extension of the vagina, the 
 
 Fig. 38. — Development of 
 the lower urogenital tract. 
 — After Nagel. 
 
 aulai^e of the cervix, at first on a level 
 
 with the lower ends of the Wolffian ducts, 
 
 and in very close relationship with them, 
 
 is moved gradually farther away from ^^^^ ^j^g^^^ represents the 
 
 the urogenital sinus, and with it, conse- ureters and Wolffian ducts 
 
 quently, the Wolffian ducts are moved (dotted line), opening at the 
 
 farther away. "^""^ '?^f °"* j"'° '^^ «^^'y 
 
 , . ,r I'll 11, 1 urogenital canal. 
 
 It is, therefore, highly probable that 
 
 the small crypts, known a.s Skene's or Malpighi's, or para-urethral ducts, 
 
 are not derived from the Wolffian canals. According to Nagel these 
 
 ducts are formed in early embryonic life by a depression of the 
 
 epithelium covering the urogenital sinus, at a time when the Wolffian 
 
 ducts have disappeared from the region of the vagina and bladder. 
 
 Very strong, too, is the evidence derived from pathological changes 
 
 in the remnants of the Wi !ffian ducts. For a long time it has been 
 
 known that the chief seat of such conditions is the broad ligament. 
 
 Recently von Recklinghausen has shown, in an important monograph, 
 
 that Wolffian remains may play an important part in the formation of 
 
 adenomyoma and cystic adenoma of the wall of the tube or uterus. In 
 
 the twenty-eight cases carefully studied by him, twenty-three presented 
 
 these pathological conditions in the tube wall or upper part of the 
 
 corpus uteri ; but only in four cases could any trace of the Wolffian 
 
 ducts be found below the level of the body of the uterus, and then only 
 
 in the upper part of the cervix. 
 
 ■„rt 
 
 
68 
 
 THE RECTUM. 
 
 Cystic conditions below the level of the cervix are extremely rare. 
 In the majority of cases they are lined with a single layer of cylindrical 
 
 Fir.. 39. — Development of 
 lower urogenital tract. 
 —After Nagkl. 
 
 The ureters and WolflTian ducts 
 are represented opening into 
 the urogenital canal at differ- 
 ent levels. The Miillerian 
 tract (heavy line) has reached 
 the canal. The bladder has 
 begun to develop. 
 
 Fifi. 40. — Development of the 
 lower urogenital tract. — After 
 Nagbl. 
 
 The vagina is represented as com- 
 pletely developed. Above it is seen 
 a remnant of the Wolffian ducts. The 
 bladder and urethra have become 
 differentiated. 
 
 epithelium, sometimes with squamous epithelium. As to the Miillerian 
 or Wolffian origin of these, no decision can he formed at present. Pro- 
 bably they are derived from both sources, most rarely from the latter. 
 
 THE RECTUM. 
 
 This part of the large intestine extends from the sigmoid 
 flexure at the left sacro-iliac joint to the anus. The first 
 part, 4 or 5 in. long, passes downwards, backwards, and to 
 the right, as far as the middle of the third sacral vertebra ; 
 often this portion is displaced to the right half of the pelvis. 
 It is covered almost completely in peritoneum, the two 
 folds of which are attached to the sacrum as the meso- 
 rectum. 
 
 The second part, 3 or 4 in. long, extends down and 
 
STRUCTURE. 
 
 69 
 
 forwards to the anal canal. In its upper part it is covered 
 with the peritoneum, reflected from the posterior vaginal 
 wall. ---• 
 
 Below this the bowel is in relation anteriorly to the 
 posterior vaginal wall. Its posterior wall is in relation to 
 the sacrum, coccyx, and the ano-coccygeal body. 
 
 Structure. — The muscular wall is thick and consists of 
 longitudinal and circular layers. The former extends all 
 around the bowels, but is mainly aggregated in two 
 bundles — an anterior and a posterior. The shortness of 
 these leads to the sacculations found in the rectum. 
 
 The circular fibres are especially collected in thick 
 bundles between the sacculations. 
 
 In addition, a small pair of muscles arise from the front 
 of the second and tnird coccygeal vertebrce and pelvic 
 fascia, and pass down to the posterior part of the anal 
 canal, mingling with the longitudinal fibres. They are 
 the rectococcygeal muscles. 
 
 The m ous membrane is loosely connected to the 
 muscular coat. When the rectum is empty and con- 
 tracted, it presents numerous folds, most of which are 
 obliterated when the bowel is distended. Some are per- 
 manent and are known as " valves " of the rectum or 
 "pliccX recti." The largest is on the right side opposite 
 the reflection of the peritoneum, the '■''plica transversals 
 redi.^'' On the left side, an inch above this, is another ; 
 and, an inch below, another, on the left side. The lower 
 two folds together form a partial closure of the bowel, 
 easily distinguishable by the examining finger. This 
 sphincter-like arrangement has been called the "third 
 sphincter of the anus." 
 
 The dilf'.tation of the bowel below this valve is called 
 the ampulla of the rectum. 
 
 The anal canal is the terminal portion of the rectum, 
 surrounded by sphincters. It is an antero-posterior slit in 
 the pelvic floor when closed, and is thus to be distinguished 
 
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 IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
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 U III 1.6 
 
 Photographic 
 
 Sciences 
 
 Corporation 
 
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 23 WEST MAIN ST.^EET 
 
 WEBSTER, NY. 14580 
 
 (716) 872-4503 
 
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 V. 
 
 70 
 
 THE RECTUM. 
 
 from the lower part of the rectum, which is a transverse slit. 
 It is an inch long in the empty condition of the rectum, 
 shorter when the latter is loaded. It is directed down- 
 wards and backwards, and is related behind to the ano- 
 co'^cygeal body ; at the sides, to the ischio-rectal fat ; in 
 front, to the perineum. 
 
 Its mucous membrane is arranged in four or five longi- 
 tudinal folds, the columns of the rectum. 
 
 The muscles which close the anal canal are the external 
 and internal sphincters and the levatores ani. 
 
 The external sphincter is elliptical in form, and is placed 
 beneath the skin around the margin of the anus. 
 
 The internal sphincter is continuous with the circular 
 fibres of the rectum. 
 
 The levatores ani are described on p. 8i. 
 
 The mucosa of the rectum and greater part of the anal 
 canal is lined with columnar epithelium, and contains 
 follicles of Lieberkiihn closely arranged. 
 
 A narrow zone of the anu^ internal to the skin has no 
 follicles. Its mucosa gradually changes into a skin-like 
 character towards the margin of the anus. 
 
CHAPTER III. 
 
 ( * 
 
 THE PELVIC PERITONEUM. 
 
 As the peritoneum descends from the posterior abdom- 
 inal wall, it covers the first part of the rectum, forming a 
 mesorectum^ which is attached to the sacrum. 
 
 Gradually it leaves the gut posteriorly, then laterally, 
 and then the anterior surface of the second portion of 
 the rectum, being reflected on the posterior vaginal wall 
 \-\ in. below the attachment of the latter tc the uterus. 
 It then spreads over the fundus of the uterus down its 
 anterior wall, and at the level of the isthmus is reflected 
 to the superior surface of the bladder, and then to the 
 back of the upper part of the symphysis. At each side 
 of the bladder it leaves that viscus along the line of the 
 obliterated hypogastric artery, and passes to the pelvic wall. 
 
 From each lateral edge of the uterus, the peritoneum 
 extends out as a double layer — the broad ligament— io the 
 side wall of the pelvis. 
 
 The broad ligaments. — Each one extends from the 
 uterus to the side wall of the pelvis, in front of the sacro- 
 iliac joint, slightly behind the level of the transverse pelvic 
 diameter. 
 
 The folds are close together in tho main extent of 
 the ligaments, but towards their base and towards their 
 outer part they separate somewhat, there being more con- 
 nective tissue in those portions. The upper free border is 
 occupied in most of its extent by the Fallopian tube. 
 
 They contain mainly connective tissue. In their lower 
 
 % 
 
 u 
 
V. 
 
 72 
 
 THE PEL VIC PERITONEUM, 
 
 parts is found a thin layer of smooth muscular fibres, 
 continuous with those of the outer layer of the uterus and 
 bladder. In the upper portions, very few muscular fibres 
 are found ; here the layers of the ligament can be easily 
 moved on one another. 
 
 The portion outside the tube encloses the ovarian vessels 
 and extends above the pelvic brim as the suspensory 
 ligament (infundibulo-pelvic) of the ovary. Between the 
 ovary and the uterus is a fold of the posterior layer, 
 forming the ovarian ligament {vide p. 2). A fold of the 
 anterior layer is also seen passing from the angle of the 
 body of the uterus and enclosing the round ligament of 
 the uterus {vide p. 30). Projecting from the posterior 
 surface is the ovary iodide p. 3), and within its laminae 
 are the remains of the Wolffian body and duct, besides 
 vessels, nerves, etc. 
 
 The position of the broad ligament varies according to 
 that of the uterus as well as according to different variations 
 in intra-abdominal pressure. 
 
 When the uterine body lies on the empty bladder, the 
 inner part of the ligament is bent downwards and forwards. 
 If there is a sharp flexion on the uterus, there is a corre- 
 sponding fold across the ligament. 
 
 The portion attached to the outer end of the tube is 
 quite movable, and may often be found folded over the 
 ovary. The fimbriated end of the tube is thereby possessed 
 with a considerable range of movement ; sometimes it may 
 be found as far back as the rectum. 
 
 The recto-vaginal pouch, or pouch of Douglas, is the 
 depression of peritoneum between the supravaginal por- 
 tion of the uterus and the upper part of the vagina in 
 front, and the second part of the rectum behind. Laterally, 
 the upper boundaries are best described as the utero-sacral 
 ligaments. The pouch is often deeper on the left than on 
 the right side. This is the lowest part of the peritoneal 
 cavity in the erect posture. Normally the intestines do 
 
 li 
 
 \\ 
 
THE BROAD LIGAMENTS. 
 
 73 
 
 not descend into the pouch. Sometimes the pouch dips 
 abnormally low into the perineal body. Sometimes it is 
 rather high, near the top of the fornix. 
 
 The utero-vesical pouch is that between the uterus and 
 bladder, bounded laterally by the utero-vesical folds (false 
 ligaments) of peritoneum. Normally, no intestines lie in 
 this pouch. In ihe retroverted condition of the uterus ihey 
 are found there, however. 
 
 Development of broad ligaments. —Each arises from an up- 
 growth of the epithelial covering and subjacent tissue of the Wolffian 
 body in the shape of a fold. 
 
 I. 
 
 CONNECTIVE TISSUE OF THE PELVIS. 
 
 Under this heading must be noted (i) the dense fascial 
 layers known as the pelvic fascia^ of importance in rela- 
 
 FiG. 41.— Coronal section through the pelvis, showing the 
 relation of uterus and vagina to the laterully placed 
 extra-peritoneal tissues. 
 
 tion to the support of organs and to the strengthening 
 of the pelvic floor ; and (2) the loose connective tissue 
 between the various layers of the former, between muscles, 
 and surrounding bladder, urethra, vagina, and rectum, of 
 importance in relation to inflammation. The first of these 
 has received scant attention at the hands of gynecolo- 
 gists. I have given it a prominent place in the considera- 
 
 1" 
 '1, 
 
V 
 
 
 
 74 
 
 THE PELVIC FLOOR. 
 
 tion of the nature of the pelvic floor, as I believe this 
 necessary to establish a correct understanding of this 
 important structure (^ide p. 76). 
 
 The loose connective tissue to which reference must be 
 made is found in the broad (lateral parametric) and utero- 
 sacral ligaments (posterior parametric), at the sides of the 
 bladder (paravesical), around the rectum (paraproctal). 
 between the bladder and the cervix, on the side wall of the 
 pelvis, in the round ligaments, around the upper portion of 
 the vagina (paravaginal). 
 
 Most important of these, as regards the frequency cf 
 inflammation in them, are the broad and utero-sacral 
 ligaments. 
 
 '* THE PELVIC FLOOR. 
 
 I shall consider this subject under the following heads : — 
 
 L The Meaning of the Term " Pelvic Floor." 
 IL The Floor Studied by Dissection. 
 IIL The Floor Studied by Frozen Sections. 
 IV. The Physics of the Pelvic Floor. 
 
 I. The Meaning of the Term "Pelvic Floor." 
 
 The term " floor " is not a good one, since it leads one to 
 think of the floor of a house, e.g. a rigid partition running 
 transversely between walls. Consequently, in looking for 
 a floor in the pelvis, we are apt to seek for something which 
 has the character of a house floor. The pelvic floor has 
 no such structure. It is not a rigid partition, nor does it 
 run transversely. It is elastic and movable, varying in 
 its thickness, its nature, and its slope at various parts, 
 while it runs across a very irregularly-shaped space — the 
 outlet of the bony pelvis. It is composed of a variety 
 of tissues, differing in their consistence, their strength, 
 and the firmness of their attachment to the bony wall. 
 The great purpose of the pelvic floor, as a floor, is un- 
 
 fv 
 
MEANING OF THE TERM. 
 
 75 
 
 doubtedly to sustair the weight of the great mass of 
 abdominal viscera, or, in other words, to resist the intra- 
 abdominal pressure. As Hart has shown, an increase in 
 the intra-abdominal pressure, a weakening of the floor, 
 or both these conditions combined, may lead to a hernial 
 protrusion of the floor, just as corresponding conditions in 
 the abdominal wall produce a similar result. 
 
 In strict anatomical accuracy, therefore, it must be 
 admitted that all those structures in connection with the 
 pelvic outlet which help to resist and support this pressure, 
 and whose removal would be a source of weakness, must be 
 considered as forming a part of the floor. While sectional 
 anatomy is of the greatest value in demonstrating the 
 nature of the floor as a whole, there can be no doubt 
 that dissectional work is the only method we possess of 
 analysing its constituent elements and the part they play 
 in resisting the intra-abdominal pressure. Neither Hart 
 nor Symington have, it seems to me, given at all sufiicient 
 prominence to this method of study in their papers on the 
 pelvic floor, formulating their conclusions almost entirely 
 from the examination of sections. 
 
 According to Hart, whose views have been mainly 
 followed during the last fourteen years, the floor is composed 
 of those tissues which close the outlet of the pelvis, being 
 bounded by skin externally and by peritoneum internally, 
 the uterus and appendages being removed. He divides it 
 into an anterior part called the pubic segment, and a 
 posterior part called the sacral segment, the line of division 
 between the two being the vaginal slit. Studied in vertical 
 mesial section, the former is seen to be triangular in shape, 
 loose in texture, loosely attached to the pelvis, and to 
 include the structures lying between the symphysis and 
 the vaginal slit, being chiefly composed of bladder, urethral 
 and anterior vaginal walls ; the latter, stiong in structure, 
 embraces the tissues between the vaginal slit and posterior 
 bony wall, firmly dovetailed into the sides of the latter. 
 
 
76 
 
 THE PEL VIC FLOOR. 
 
 r I. 
 
 1 
 
 Symington, on the other hand, considers " that the rectum 
 and the bladder, like the uterus, should not be regarded 
 as parts of the pelvic floor, but as organs resting upon it." 
 He further says, that " the interior part of the pelvic floor 
 is composed of firm tissue, and is connected as strongly 
 with the anterior part of the pelvic wall as is the sacral 
 segment with the sacrum and coccyx." He also says that 
 " only the lower half of the vagina is in the pelvic floor." 
 Both of these authors have formed these different conclu- 
 sions from their study of the pelvis by frozen sections. 
 
 . 
 
 
 II. The Floor Studied by Dissection. 
 
 Dissection is of prime importance, and should precede 
 all other methods of studying the floor, for by it alone do 
 
 we gain a true knowledge 
 of the nature of the floor 
 and of the complex ar- 
 rangement of the struc- 
 tures composing it. I 
 shall describe these struc- 
 tures singly, and discuss 
 the value of each in re- 
 gard to the support and 
 strength given by it to 
 the floor. 
 
 I. Pelvic fascia. — 
 This structure is, un- 
 doubtedly, of the very 
 greatest value in resisting 
 the intra-abdominal pres- 
 sure at the pelvic outlet. 
 I. Parietal LAYER. — 
 In front, this layer, a 
 strong aponeurotic membrane, for the most part, is continued 
 across the subpubic arch, as the so-called " posterior layer of 
 
 Fig. 42. — Front of pelvis from within, 
 showing the relation of urethra and 
 vagina to posterior layer of triangular 
 ligament. Part of the pubo-coccy- 
 geus and obturator-coccygeus are also 
 shown.— Savage. 
 
 l\ 
 
THE PEL VIC FASCIA. 
 
 77 
 
 the triangular ligament." Its lower border blends with the 
 base of the so-called "anterior layer of the triangular 
 ligament" (triangular ligament proper), which is attached 
 at its apex to the subpubic ligament, by its base to the 
 superficial fascia and central point of the perineum, and by 
 its sides to the pubic arch. It is perforated by the urethra 
 and vagina, and is thereby considerably weakened. This 
 
 ■^j 
 
 Fig. 43. — Portion of pelvis seen from the front. The clitoris, 
 its crura and suspensory lig.nment are shown. On the 
 right side the anterior layer of the triangular ligament 
 is shown, and on the left the posterior layer. The 
 urethra and vagina are also seen. — Savage, 
 
 layer is never recognised as a distinct membrane in frozen 
 sections because it is so blended with adjacent structures ; 
 it certainly forms part of the pelvic floor, strengthening its 
 anterior part, helping to support and steady the urethra and 
 vagina as well as the perineum. In the posterior part of 
 the pelvis the parietal layer plays a less important part in 
 helping to bridge across the greater and lesser sacro-sciatic 
 notches. Here the great and small sacro-sciatic ligaments 
 are the most important supports, though the parietal fascia 
 internal to them and attached to them is an additional 
 

 U' 
 
 I 
 
 78 
 
 THE PELVIC FLOOR. 
 
 source of strength. I do not think tliat the importance 
 of the sacro-sciatic ligaments in regard to the mechanism 
 of labour has been sufficiently noticed. From their position 
 and strength they must influence considerably the course of 
 the various parts of the foetus as they appear successively 
 at the pelvic floor in labour. As the coccyx is driven 
 downwards and backwards they must also be considerably 
 stretched. 
 
 2. Visceral layer. — This layer and '^'"' divisions are 
 scarcely noticed by most writers in obstetrics. The pelvic 
 
 fascia is generally studied 
 in the dissecting-room in 
 the male ; its arrangement 
 in the female is not usually 
 dwelt on to any consider- 
 able extent. 
 
 There can be no doubt 
 that it forms an important 
 resisting structure to the 
 intra-abdominal pressure. 
 What is its disposition ? 
 In the greater part of its 
 extent it springs from the 
 parietal layer along the 
 white line. This white line passes around the pelvic wall from 
 the ischial spine behind to a point on the posterior surface 
 of the symphysis pubis, a little above its lower end. The 
 visceral layer passes inwards, on each side, upon the upper 
 surface of the levator ani to the lateral walls of the bladder, 
 vagina, and rectum, where it divides into four layers : — 
 
 {a) Vesical layer. — This layer turns upwards upon the 
 lower lateral aspect of the bladder, forming the ''''lateral 
 true ligament of the bladder.^'' It is in firm union with the 
 bladder wall, and thins as it passes upwards over the 
 bladder, to be continuous with the corresponding layer of 
 the opposite side. 
 
 Fig. 44. — Parietal pelvic fascia seen 
 from within. — Savagk. 
 
 -i 
 
THE PELVIC FASCIA. 
 
 79 
 
 (Jt) Vesko-vaginal layer. — This layer, thin but strong, 
 passes between the bladder and the anterior vaginal wall, 
 being in firm union with both, and being continuous with 
 the corresponding layer of the opposite side. At its 
 posterior part it blends with the connective tissue which 
 attaches the posterior part of the bladder to the neck of 
 the uterus. 
 
 {c) Recto-vagina/ layer. — This layer passes between the 
 
 W 
 
 Fig. 45. — Superficial dissection of perineum and vulvar region, 
 showing deep layer of perineal fascia. — Savagk. 
 
 vagina and the anterior wall of the lower part of the rectum. 
 Except for a short distance behind the upper part of the 
 vagina, the union between this layer and the vaginal and rectal 
 walls is very firm. Below it is continuous with the strong 
 connective tissue elements of the perineal body. It is con- 
 tinuous with the corresponding layer of the opposite side. 
 
 {d) Rectal layer. — This layer passes behind the rectum, 
 attached to its walls, and joins the corresponding layer of 
 the opposite side. It is prolonged downwards as a thin 
 
80 
 
 THE PET. VrC FLOOR. 
 
 \ 
 
 layer towards the lowest part of the gut, being, of course, 
 internal to the levator ani. 
 
 These layers in sections are not always made out with 
 ease as distinct fascial structures, on account of their in- 
 timate blending with surrounding parts. They are more 
 readily made out by dissection when traced from their 
 parietal origin inwards in the uncut pelvis. 
 
 They are of great significance, and are undoubtedly of 
 chief importance iti slinging the Madder, the vagina, and the 
 loiver part of the rectum in the pelvis. In most obstetrical 
 and gynecological works I find no mention of them whatever. 
 
 {e) Anterior visceral layer. — Further, the arrangement of 
 the visceral fascia in the anterior part of the pelvis is of 
 considerable importance. Here the visceral layer, arising 
 from the back of the lower part of the pubes on each side 
 of the middle line, above the point of origin of the anterior 
 fibres of the levatores ani, as well as the attachment of the 
 parietal fascia, passes backwards as two strong bands above 
 them and on each side of the urethra to become blended with 
 the anterior surface of the bladder. These are the anterior 
 true ligaments of the bladder. Between them is a space 
 filled with loose connective tissue and fat, continuous 
 below with the retropubic fat and above with the supra- 
 pubic or retroperitoneal fat. 
 
 (/) Anal fascia. — Lastly, there is a thin aponeurotic 
 membrane, which arises from the parietal fascia along the 
 white line under the attachment of the levator ani, and 
 passes downwards, closely attached to the muscle, and 
 blending with the corresponding layer of the other side 
 and with the other connective tissue elements of the 
 perineum. In front it is attached to the posterior layer 
 of the triangular ligament (parietal pelvic fascia). This 
 layer is called by some the anal fascia, and by others the 
 aponeurosis of the levator ani. 
 
 II. Superficial fascia. — Under the skin, over all the 
 lowermost part of the pelvic floor, is a well-marked layer 
 
 L 
 
) 
 
 THE PEL VIC MUSCLES. 
 
 8i 
 
 the 
 ayer 
 
 of superficial fascia. Towards the skin it consists of fine 
 fibrous trabecular containing a large (juantity of fat, which 
 is most abundant behind and on each side of the anus ; 
 over the tuberosities of the ischium, this superficial fascia 
 becomes tough and stringy, the fibrous septa being thicker 
 and stronger, attaching the skin to the bone. The deep 
 layer is of more importance, being dense and aponeurotic, 
 and giving considerable 
 strength to the pelvic floor 
 through its attachments. 
 Anteriorly it is attached to 
 the lower edge of the pubic 
 and ischial rami, extending 
 back almost to the tuber- 
 osities \ posteriorly it blendu 
 in the perineum with the 
 base of the triangular liga- 
 ment. 
 
 III. Pelvic muscles en- 
 tering into the floor. — 
 Levatores ani. — These 
 muscles together form a 
 muscular diaphragm with 
 the concavity upwards. 
 They are usually described 
 as being of chief value in 
 strengthening the pelvic floor. ']'hat they are the most 
 important muscles in the floor is true ; but on account 
 of their thinness t seems to me that they cannot per 
 se exercise a very great influence in resisting the intra- 
 abdominal pressure. Savage divides each into two portions, 
 namely, the pubo-coccy^eus and the obturator-coccygeus. Sym- 
 ington has well described the arrangement and functions of 
 these. 
 
 The pubo-coccygens passing on each side, from the back 
 of the pubes to the last two pieces of the coccyx, act as 
 6 
 
 Fig. 46. — Dissection of pelvic floor, 
 showing tiic muscles from below. 
 On each side is shown the erector 
 clitoridis, bulbo-eavernosus, trans- 
 versus perinei superficialis, sphincter, 
 ani externus, levator ani, coccygcus, 
 gluteus maximus. — Savage. 
 
V } 
 
 82 
 
 7'J^£ PELVIC I' LOOK. 
 
 sphincters of the lower part of the vagina and the anal 
 canal, and tend to draw ui)wards and forwards the perineal 
 body and coccyx. A few fibres blend with the urethral 
 and vaginal \\alls, others turn inwards in the perineal body 
 in front of the internal spliincter of the anus ; behind the 
 anus there is a blending of some fibres of opposite sides. 
 
 The o/>iiira/or-coaygeiis, the main i)art of the muscle, 
 arises '"rom the white line between the pubes and the 
 
 Fig. 47. — Part of pelvis showing the levator ani and coccygcus 
 muscles I'roni above. I'arts of the bladder, vagina, and 
 rectum are shown. — Savagi;. 
 
 ischial spine. It runs backwards, downwards, and inwards 
 to the sides of the coccyx. With these should be associated 
 the thin cvccyi^ei muscles which arise from the ischial si)ines 
 and small sacro-sciatic ligaments and are inserted into the 
 sides of the last sacral and the coccygeal vertebrre. They 
 have no direct action upon the pelvic viscera. They help 
 to fill in the sides and posterior part of the pelvic outlet ; 
 they resist somewhat the intra-abdominal pressure, and they 
 can elevate the coccyx after it has been bent downwards. 
 This is quite different from the ordinary impression which 
 
THE PEL VIC MUSCLES, 
 
 S3 
 
 the student has regarding the arrangement of these muscles. 
 It is usually understood that the great mass of the /ci'afor 
 cud arising from the white line passes downwards and in- 
 wards and, while being attached behind to the coccyx, 
 mainly converges towards the middle line, whei i it blends 
 with the muscle of the opposite side in the [)erineal body 
 and behind the anus. Coront.l sections are largely to 
 blame for giving this false impression. For example. Hart 
 and ]jarbour in their des- 
 cription of a coronal section 
 of Barbour's passing through 
 the obturator interims mus- 
 lie, describe the levator aid 
 as arising from the white line 
 and as passing down to be 
 inserted into the perineal 
 body. The truth is, that 
 the main part of the muscle 
 arising from the white line 
 passes backwards to be at- 
 tached to the coccyx and Fkj. 48 — Dissocuon of pelvis blunv- 
 lower part of the sacrum, i"S Icvatoios ani ami coccygei 
 1 .,, ,1 ^ ,,^ ,.»^„.,,i nmsolcs of each side from above. 
 
 and meets the correspond- ,, , . 
 
 ^ . Relations to urethra, vaijiiia, and 
 
 ing portion of the opposite r^.^tum are shown.-SAVACJK. 
 
 side in the middle line, 
 
 only at the tip of the coccyx. It is the anterior and 
 
 smaller portion, the so-called pubo-coccyi::;eus^ which alone, by 
 
 means of its attachment to the urethral and vaginal walls 
 
 and by its blending with the corresponding muscles of the 
 
 opposite side in the perineum and behind the anus, helps 
 
 to strengthen the pelvic outlet across the middle line. Its 
 
 outer fibres are, of course, parallel to and continuous with 
 
 the obtiirator-a)icyi:;eus, and hence the utterly erroneous 
 
 impression which the coronal sections give of the levator 
 
 aid arising from the white line and being inserted into the 
 
 l)crineum. The presence of the vaginal slit is a great 
 
 >' 
 
 Jll ^tTWPlWgW^BtWWW^W 
 
V 
 
 \i 
 
 84 
 
 r//£ PELVIC FLOOR, 
 
 source of weakness to this muscle. The value of the 
 levator am to the pelvic floor has, indeed, no doubt, been 
 greatly overstated. Kelly goes so far as to describe the 
 muscular part of the floor as its principal strength. If one 
 imagines the visceral portions of the pelvic fascia and the anal 
 fascia removed, it is not difficult to realise the comparative 
 weakness of the muscular diaphragm in supporting the 
 intra-abdominal pressure. 
 
 The other muscles of the pelvic floor play a very small part 
 
 in strengthening it. The 
 transversiis perinei is a very 
 small muscle, very difficult to 
 define, and less developed in 
 the female than in the male. 
 The sphincter v agin re 
 helps, in a very small de- 
 gree, to strengthen the floor 
 through its sphincter action 
 on the vagina (though, ac- 
 cording to wSymington, this 
 is very slight, its main action 
 being merely to compress 
 the vestibular bulb) as well 
 as through its attachment 
 to the clitoris in front and 
 to the central point of the 
 perineum behind. 
 The sphincter ani in the same way helps by its sphincter 
 action on the anus as well as through its attachment to the 
 central point of the perineum in front and the tip of the 
 coccyx behind. 
 
 The compressor 7( re three or *"ansversus perinei profundus, 
 arising from the inner aspect of the junction of the rami of 
 the pubes and ischium, passes in front of the urethra and 
 behind the vagina, being also attached to their walls, and 
 blends with the corresponding muscle of the opposite side. 
 
 Fig. 49. — Deep dissection of perineal 
 and vulvar regions. The deep 
 layer and base of the triangular 
 ligament are seen, also the anal 
 fascia covering the levatorcs ani. 
 — Savagk. 
 
VISCERA AND PASSAGES. 
 
 85 
 
 These four muscles are very small, and while undoubtedly 
 helping to consolidate and strengthen the floor, play but a 
 minor part in this capacity. 
 
 Gluteus maximus. — The lower part of this muscle as 
 it passes downwards and forwards from the side of the 
 coccyx over the ischial tuberosity is a source of strength 
 to the pelvic floor in its posterior and outer part. 
 
 IV. Viscera and passages connected with pelvic floor. 
 — Certain viscera are connected with the floor ; certain 
 passages pierce tli" floor. Are they to be described as 
 forming part of the fl'^'^r? Hart describes the bladder 
 and urethra, the vagina and the rectum as forming part 
 of the floor, the uterus and appendages resting upon it. 
 Symington differs from Hart in saying that the upper part 
 of the bladder, the upper part of the vagina, and the 
 rectum are not a part of the floor. E.anney and Foster 
 differ from Hart in including the uterus. 
 
 Putting aside for the present all considerations regarding 
 parturition, prolapsus uteri, the action of pessaries, etc., let 
 us ascertain the truth from a purely anatomical standpoint. 
 
 Bladder. — This organ, independent of its being empty 
 or filled, cannot but be considered as having a very intimate 
 connection with the anterior part of the floor. Per se it 
 does not resist the intra-abdominal pressure ; through its 
 connections, and those of the urethra, by which it is slung 
 in the pelvis, it does perform this function to a very con- 
 siderable extent. 
 
 These connections as as follows : — 
 
 Fascial, — Anterior and lateral true ligaments ; vesico- 
 vaginal layer of the visceral pelvic fascia ; triangular 
 ligament. 
 
 Muscular. — Pubo-coccygeus division of levator ani ; 
 transversus perinei profundus. 
 
 Ordinary connective tissue. — That connecting it with the 
 bony wall and the structures in immediate relation to the 
 bladder and urethra. 
 
 ■I 
 
 I 
 

 V 
 
 86 
 
 THE PELVIC FLOOR. 
 
 Peritoneal. — False ligaments (unimportant). 
 
 Other structures. — Urachus ; obliterated hypogastric 
 arteries ; ureters. 
 
 Of all these, its connections with the pelvic wall through 
 the visceral layers of the pelvic fascia are the most im- 
 portant. 
 
 Symington and Croom urge that the bladder should be 
 regarded as resting upon the pelvic floor. The anatomy 
 of the parts shows that it is embedded in the floor. 
 Further, they say that because the organ fills and empties 
 it cannot be considered as part of the floor. Is not this 
 objection of the nature of a quibble ? Are the anatomical 
 connections not the same in all conditions of the bladder ? 
 If between two posts we tie a rope, forming a kind of 
 suspension bridge, and then, cutting the rope in two, attach 
 between the ends a strong bag which can be filled and 
 emptied, — is the bag, because it is hollow, and capable of 
 being filled and em])licd, not to be considered as forming 
 part of the bridge ^ The analogy is a fair one. I'he 
 bladder is simply a bag slung between the walls of the 
 anterior and lower paiL of the pelvis. 
 
 Vagina. — The wall of this passage is slung in the pelvis 
 by fascial and muscular attachments, and is thereby made 
 to form an intimate portion of the pelvic floor. 
 
 These attachments are as follows : — 
 
 Fascial. — Triangular ligament which it pierces; vesico- 
 vaginal layer of visceral pelvic fascia ; vagino-rectal layer. 
 
 Muscular. — Pubo-coccygeus division of levator ani ; 
 sphincter vaginn2 ; transversus pcrinei profundus. 
 
 Ordiuaj-y couuective tissue. — That connecting it with 
 the bony wall. 
 
 Secondary. — Through its very firm junction with the 
 urethra, the base of the bladder and the lower part of 
 the rectum, it is supported by the attachments of these 
 structures. 
 
 The analogy made in reference to the bladder will apply 
 
 (\ 
 
THE RECTUM. 
 
 9- 
 
 here again. Symington is unwarranted, I think, in making 
 the greater portion of the vaginal wall worthy of a place in 
 the pelvic floor, and at the same time excluding the upper 
 portion of the vaginal wall. His coronal section, passing 
 through this portion, has evidently blind(^d him to the 
 wider relationships of the vagina. That the upper part of 
 the vagina is less strongly united to the bladder and rectum 
 than the lower and larger part is to the structures in front 
 and behind it, cannot be disputed. These connections are 
 of small importance, /// ;r the part they play in the pelvic 
 floor. It is its lateral attachments to the pelvic wall, by 
 means of the fascial structures of the floor, which are of 
 chief importance. I quite admit, however, that the vesico- 
 vaginal and r^cto-vaginal layers are thinner and weaker in 
 their upper part than elsewhere. 
 
 Rectum. — Most of the authors already quoted are not 
 precise \\\ their reference to this structure. All are agreed 
 that the lower portion of the wall of the gut forming the 
 anus is an intimate part of the floor. It is disputed as to 
 where the upper limit ends. 'Hie so-called first part of the 
 rectum — that part provided with a mesentery, must be 
 excluded. The second part, which extends from the first 
 part to the tip of the coccyx and resting against the sacrum, 
 coccyx, obturator-coccygeus part of the levator ani, and the 
 coccygeus itself, to all of which it is attached, cannot be 
 considered as forming a part of the pelvic floor, since the 
 intra-abdominal pressure tends to push it, not out of the 
 pelvis, but against the posierior wall. 
 
 From the coccyx downwards the wall is a part of the 
 pelvic floor, its attachments being as follows : — 
 
 Fascial. — Recto- vaginal layer of visceral pelvic fascia ; 
 rectal layer of visceral pelvic fascia. 
 
 Muscular. — Pubo-coccygeus portion of levator ani ; 
 sphincter ani. 
 
 Connective tissue. — That connecting it with surrounding 
 parts and >v" "> the bony wall. 
 
 m 
 
V 
 
 88 
 
 THE PELVIC FLOOR. 
 
 \ 
 
 Secondary. — Through its attachments to the posterior 
 vaginal wall and perineum. 
 
 The lowest part of the rectum, therefore, is, like the 
 vagina, a tube slung between the sides of the pelvis by the 
 fascial tissues of the floor, supported by certain muscles as 
 well as by the vaginal and perineal attachments. 
 
 It must be borne in mind that the gut is quite closed 
 unless distended by flatus or fteces. 
 
 Uterus. — Has this organ no claim to be considered part 
 of the pelvic floor? According to Hart it has not. He 
 says that it merely rests on the floor, not being suspended. 
 He compares it to the male bladder, which he regards as 
 resting upon the pelvic floor, its ligaments having nothing 
 to do with its support. This statement is opposed to all 
 the teaching of anatomists. I can find no one who at all 
 agrees with him in this view. It is sutficient to quote from 
 Sir William Turner: — "Passing to the bladder are two 
 important membranes which, together with its vessels and 
 ducts, retain it in posi'aon. These membranes are the 
 peritoneum and the pelvic fascia." Hart strenuously con- 
 tends that the fetnale bladder is a portion of the pelvic floor, 
 and it is impossible to understand why he should not place 
 the male organ in the same category, since they are both 
 attached to the bony wall in practically the same manner. 
 His comparison of the uterus to bladder is, therefore, from 
 his point of view, a bad one. 
 
 What, now, are the connections of the uterus ? 
 
 I. In THE FfETUS. — The common origin of the uterus and 
 vagina from the fusion of the lower parts of the Miillerian 
 ducts must be remembered. In the third and fourth 
 months there is no distinction between the uterus and 
 vagina. After this the uterine wall gradually becomes 
 thicker, especially in the cervical portion, while a vaginal 
 portion at the same time develops. The important fact to 
 be noted, however, is that while the uterus is, in the foetus, 
 relatively higher than in the adult condition, in other 
 
 !\ 
 
THE UTERUS. 
 
 89 
 
 respects it has relations the reverse of those existing in the 
 adult condition. 
 
 Thus, in the fojtus, the cervix is both very much longer, 
 as well as wider than the body — exactly the reverse of the 
 adult condition. In the foetus the thickness of the cervix 
 in proportion to the pelvic diameter is relatively greater 
 than in the adult condition. In the foetus there is relatively 
 much less of the uterus covered with peritoneum than in 
 the adult. The broad ligaments are, therefore, in the 
 foetus, relatively very small. 
 
 The cervix, which forms three-fourths of the whole 
 uterus, is, save on its posterior surface where it is covered 
 with peritoneum, firmly embedded in the fascial and con- 
 nective tissue structures, below the peritoneum. In front 
 it is attached to the bladder, which extends across the pelvis 
 from side to side, the vesico-vaginal layer of pelvic fascia 
 passing between them and being connected with both ; 
 laterally it is connected with the pelvic wall. From its 
 large size, relative to the width of the pelvic cavity, it is 
 relatively nearer the wall in the adult condition. In several 
 of my cases, from being somewhat nearer one side than 
 the other, the attachment is very short, and the cervix is 
 practically fixed in position. 
 
 Iti the foetus atid new-born child it is evident, therefore, 
 that the pelvic floor is relatively thicker, and occupies more of 
 the pelvis thati i?i the adult. The greater portion of the 
 titerus — the cervix — is also, in the early period of life, an 
 intimate part of the floor. 
 
 2. In the adult. — The change from the foetal to the 
 adult condition is characterised by a marked increase in the 
 length and width of the body in relation to the cervix of 
 the uterus. The greater part of the organ is now covered 
 with peritoneum, the broad ligaments being in relation to 
 much more of the uterus than in early life. Owing also to 
 the great growth of the pelvis, the cervix relative to the 
 pelvic cavity is very much smaller than in the foetus and 
 
 ii 
 
V 
 
 90 
 
 THE PELVIC FLOOR. 
 
 is relatively, therefore, at a fnrthcr distance from its 
 walls. 
 
 What, then, are the adult attachments of the uterus ? 
 
 Fascial. —Posterior part of vesico-vaginal layer of visceral 
 pelvic fascia. 
 
 CoH/iec/ive tissue. — That attaching cervix to bladder ; that 
 attaching cervix to side walls of pelvis (parametric) ; that 
 attaching body to pelvis in the fold of the broad, utero- 
 sacral and round ligaments. 
 
 Muscular. — Non-strij)ed muscle in the broad, round, 
 utero-sacral, and utero-vesical ligaments. 
 
 Secondary. — Through its connection with the bladder and 
 the vagina, which are, as already seen, slung in the pelvis. 
 
 What importance is to be attached to these various 
 connections ? 
 
 The vesico-vaginal layer of pelvic fascia has not directly 
 much influence in supporting the uterus, since it is very 
 thin at its posterior limit, blending with the tissue joining 
 the bladder and cervix. 
 
 The tissue between the bladder and cervix, though de- 
 scribed as being loose in nature, is yet sufficient to unite 
 them intimately. It is, indeed, partly through this junction 
 that the pubic segment is elevated during labour by the 
 upward tension of uterine retraction, though, of course, the 
 tension tells mainly on the vaginal wall, with which the 
 uterine muscle is directly continuous. 
 
 Schultze points out that this connection is very rarely 
 disturbed. He says that, " not only does the uterus closely 
 follow the posterior wall of the bladder in the movements 
 due to the variations in the (quantity of the urine contained 
 in it, but the bladder also follows the anterior wall of the 
 uterus so closely, when the latter organ is displaced or 
 enlarged, that the relation of the posterior bladder wall to 
 any tumour in or above the pelvis is of great diagnostic 
 importance whenever there is any doubt as to the share the 
 uterus has in the formation of the tumour." 
 
 ! \ 
 
rilE UTERUS. 
 
 91 
 
 'I'he connective tissue between the cervix and pelvic wall 
 on each side is loose in nature. Non-striped muscle is 
 found in it. 
 
 What, now, is to be said regarding the broad ligaments? 
 Have they nothing to do witii the support of the uterus? 
 The peritoneal covering is of very little practical importance 
 in serving this purpose. Within this covering, however, is 
 fibro-niuscle and elastic tissue, which can be traced as 
 bands in several places running from the uterus to the 
 pelvic wall. The.' upper part of the ligament, which is 
 freely movable, containing the tube and ovary, can have 
 nothing to do with supporting the uterus. If one exer- 
 cise the slightest downward pressure on the uterus in the 
 cadaver, it is found that a line of resistance is formed in 
 the broad ligament running from near the cervix upwards 
 and outwards towards its ui)per parietal attachment. The 
 same thing is found during pregnancy and the pueri)erium. 
 In i)regnancy the suspending action of the ligaments is very 
 evident. 
 
 Sir William Turner says that they act as lateral i" iments 
 for the organ. 
 
 In the non-pregnant woman, in normal conditions, this 
 may scarcely at all be present, and it may serve merely to 
 steady the uterus, but if the other supports of the uterus 
 be removed, or intra-abdominal pressure be increased, then 
 the ligaments are stretched and endeavour to support the 
 organ. 
 
 In the operation of vaginal extirpation of the uterus, after 
 the organ has been divided from its vesical and vaginal 
 connections, although the vagina be distended as widely as 
 possible, the uterus does not tend to fall down, but is kept 
 in position by its ligamentous attachments. 
 
 If at this stage the uterus be pulled down to the vulva 
 and then let go, it is instantly drawn up again. Indeed, 
 the difficult part of the operation is the ligaturing of these 
 structures and the removal of the uterus from them. 
 
V 
 
 92 
 
 THE PEIJ7C FLOOR. 
 
 The utero-sacral and the utero-vesical act in much the 
 same manner as the broad h'gaments, i.e. they are in a 
 condition of somewhat elastic tension. A. R. Simj)son has 
 emphasised the fact that in tlie normal condition the uterus 
 may be pulled down to tiie vulva with ease. He says that 
 " in general the organ must descend so far as to bring the 
 OS clear through the vulva before the utero-sacral ligaments 
 are put on the stretch. It is when these become quite 
 tense that the patient has any sensation of special discom- 
 fort." This is undoubtedly true regarding parous women, 
 but in nullipara; one has to exercise more force, and even 
 then can rarely draw the uterus so far down as in parous 
 women. 
 
 It is the elastic nature of the broad and utero-sacral 
 ligaments that allows the uterus to be drawn down, and 
 which helps partly to draw it up again. As already men- 
 tioned, this may take place even when the vaginal and 
 bladder attachments are gone. 
 
 Inflammation in the ligaments renders them less elastic, 
 and makes it difficult or impossible to draw down the 
 uterus. 
 
 Where the tonicity has disappeared, and they have be- 
 come stretched and thinned, it is always a very easy matter 
 to pull down the uterus. Luschka has considered the 
 utero-sacral ligaments of such importance that he has given 
 the name of musciilaris retractor titeri to the muscular 
 tissue within them, and he says that they " determine and 
 secure the normal position of the lower end of the uterus." 
 It is objected by some that such thin folds cannot have 
 much strength. The observations of Kiistner on this point 
 are worthy of special note. He has made a special micro- 
 scopic study of the utero-sacral folds, and he says that while 
 in the free portion of the fold there is very little muscle, at 
 its lateral attachment there is a dense fiat muscular bundle. 
 He considers this almost equal in strength to the round 
 ligaments. 
 
THE UTERUS. 
 
 93 
 
 Coc says that they commonly relax under the influence 
 of an annesthetic. It is to be noted also that the utero- 
 sacral ligaments run backwards from the uterus in a direc- 
 tion practically parallel with the vagina. Through this 
 tension they undoubtedly also act through the cervix on the 
 vagina, helping to keep up its upper end. Foster, itideed, 
 says that the vagina, attached to the bone in front through 
 its connections, forms with the utero-sacral ligaments through 
 the medium of the cervix an antero-posterior beam of con- 
 siderable power. 
 
 The vaginal attachment is, it seems to me, a very 
 important support of the uterus. The vagina is slung in 
 the pelvis by the fascial layers around it, and by its attach- 
 ment to the bladder, urethra, etc. The uterus being 
 attached to the upper end of its wall is, in consequence, 
 also supported. 
 
 Schultze corroborates this view. He says that the fixation 
 of the vagina and its immediate surroundings is an essential 
 factor in securing the position of the uterus. 
 
 It is rather remarkable that Hart should place no value 
 whatever on the supporting or even steadying power of 
 these ligaments in the non-pregnant condition, but that he 
 should, when explaining the action of the retracting uterine 
 wall on the pelvic floor during labour, say that, as a result 
 of the longitudinal muscle bundles which pass into them 
 from the uterus, they afford external fixed pohits for uterine 
 action, whereby during the pains the uterus is steadied. 
 Surely this steadying and fixing power must be no incon- 
 siderable one. 
 
 From an anatomical standpoint it is evident therefore — 
 
 (a) That the uterus does not merely rest upon the pelvic 
 floor as a chair or table rests upon a house floor, as Hart 
 says it does, but that, through its cervical portion, it is 
 embedded in and forms part of the pelvic floor. 
 
 {b) That, being suspended by its vaginal and bladder 
 attachments, by the broad and utero-sacral ligaments, it, 
 
 IN 
 
 ! 
 
V 
 
 94 
 
 THE PELVIC FLOOR. 
 
 tlK-rcfoiv, as part of this susponsion-hridgc airangoniont, 
 helps to resist the intra-ahiloiniiial pressure in the same 
 manner, though not in the same de^^^ree, as tlie hhulder. 
 This resistance is less than that offered by the fascial layers 
 lower in the pelvic floor. 
 
 III. The Im.oor Studikd i'.y 1''rozen Skctions. 
 
 The vertical mesial section shows, undoubtedly, in the 
 non-pregnant woman, with parts intact, the ap[)earance first 
 described by Hart. 
 
 The pelvic floor stretches from pubes to sacrum broken 
 only by the urethra, vagina, and anus. The vagina is a 
 closed slit running practically parallel with the brim, and 
 may be considered as dividing the floor into two parts — 
 the pubic and sacral segments. ILxcluding the uterus, the 
 former has a triangular shape and the latter an irregular 
 (luadrilateral shape. 
 
 Hart describes the former as consisting of bladder, 
 urethra, anterior vaginal wall, and bladder-periton jum. Its 
 attachment to the pubes is a loose one, being separated 
 from it by a pyramidal mas:i of fat ; the posterior bladder 
 wall is loosely attached to the anterior vaginal wall, while 
 the urethra and anterior wall are closely blended. 
 
 He describes the sacral segment as consisting of rectum, 
 perineum, posterior vaginal wall, and " strong resistant 
 muscular and tendinous tissue " ; the posterior vaginal wall 
 and anterior rectal wall being loosely connected, as far down 
 as the apex of the perineal body. 
 
 From these data he generalises as follows : — 
 
 " Tlie pubic segment is loose in texture, has only a loose 
 bony attachment anteriorly, and will evidently permit of 
 mobility in an up and down direction. The sacral segment 
 is made up of dense tissue, is strong in structure, has a 
 strong dovetailed attachment to the sacrum, and is only 
 movable downwards when it revolves round the sacrum 
 
 n. 
 
V 
 
 STUD I an BY FROZEN SECTIONS. 
 
 95 
 
 and ccuryx as a whole' The weakness in the floor, due to 
 tlie presence of the vagina, is in the virgin praclieally of no 
 importance, 'i'he pubic segment c;innot shp past the sacral 
 because it is firmly pressed against it, the pressure acting at 
 right angles to the vagina. 
 
 Tl'iese are the data u[)on which Hart has chiefly based 
 his explanation of the mechanism of parturition, and to a 
 considerable extent that of prcjlapsus uteri. 
 
 Where are the fallacies in this view of the floor? 
 
 A mIsc impression as to the anatomical nature of the 
 floor la given as well as of its mechanics. 
 
 {(i) The floor is only divided into these segments by the 
 width of the vagina. The average width varies between, 
 say I in. and \% in.; the average width of the pelvic outlet 
 is 5 in. The pelvic floor is, therefore, only divided into a 
 pubic and a sacral segment in one-fourth or one-fifth of its 
 width. 
 
 {l)) Hart's description leaves out of account entirely the 
 strong fascial layers, which I have already described, and 
 which are so intimately connected to form the fascial frame- 
 work of the floor. He describes strong tendinous and 
 muscular tissues in the sacral segment, leaving them entirely 
 out of account in the pubic segment. I have already shown 
 that the visceral layers of the pelvic fascia are most strongly 
 developed in the anterior part of the pelvic floor, while the 
 pubo-coccygeus portion of the levator ani and the transverse 
 pcrlnei profundus have certainly as much influence in the 
 anterior part as in the posterior part of the floor. Hart's 
 description takes no notice either of the triangular ligament 
 or of the important layer of deep superficial fascia under 
 the skin. 
 
 These omissions are due to the fact that in sections these 
 fascial structures appear so blended with the tissues about 
 them that they are not distinguished. 
 
 (r) Though in the middle line the bladder is separated 
 from the lower part of the symphysis by loose cellular tissue 
 
V 
 
 96 
 
 THE PELVIC FLOOR. 
 
 and fat, behind the upper part it is close to the bone and 
 more firmly attached. But it is chiefly on each side that 
 the pubic segment is firmly attached to the lower part 
 of the pubes. The loose cellular tissue surrounding the 
 bladder has not the first part to play in allowing of or limit- 
 ing the movements of that organ. It is its fascial attach- 
 ments — its true ligaments. The range of movement of 
 which the bladder is capable is in reality chiefly the range 
 possessed by these ligaments. 
 
 All changes in position in the pubic segment, likewise, 
 depend primarily upon the range of movement and elasticity 
 of its fascial attachments to the bone ; secondarily, of its 
 muscular and other attachments. 
 
 {d) The description of the pubic as resting upon the sacral 
 segment is a conclusion based entirely upon a fallacious 
 conception of the pelvic floor which the vertical mesial 
 section gives, and is entirely out of keeping with the 
 structure of the floor as determined by dissection. The 
 two segments are intimately connected ; the fascial and 
 muscular suspensory arrangements of the floor are common 
 to both. The artificial division of the floor is not 
 necessary, and is only of service in aiding us to com- 
 prehend more clearly the changes which take place during 
 labour. 
 
 The perineal body. — The perineal body is situated be- 
 tween the vagina and anus. In the mass, it appears, on 
 vertical mesial section, triangular in shape, the base being 
 the skin suiface ; the sides, the anal and vaginal walls. Its 
 vertical height is about i/^ in.; the base measures from 
 before backwards | in. It is luisleading to regard it as a 
 solid mass. It is really the ce»"tral point of strength in the 
 pelvic floor, the meeting-place of important divisions of 
 the vesical pelvic fascia and of certain muscles, namely, 
 sphincter vaginae, sphincter ani externus, levator ani, trans- 
 versus perinei, bulbo-cavernosus. Tt is important in relation 
 to the ruptures which may occur in it. 
 
 ( \ 
 
s- 
 
 PHYSICS OF THE PELVIC FLOOR. 
 
 97 
 
 Above the perineal body the vaginal and rectal walls are 
 in apposition, loosely connected. 
 
 Pelvic-floor projection. — This is the projection of the 
 floor in the sagittal plane of the body beyond the conjugate 
 of the outlet. It varies in different positions of the body 
 and in various conditions of a woman's life, i.e. nulliparous, 
 multiparous, pregnant, parturient. 
 
 In the erect nullipara the greatest projection averages 
 about I in. In the multipara it is slightly less than this. 
 The outer skin measurement from the coccyx to the sub- 
 pubic ligament is in the nullipara about 5I in. 
 
 IV. Physics of the Pelvic Floor. 
 
 In considering the physics of the pelvis, it is necessary to 
 refer to the following factors : — 
 
 1. The structural arrangements and their relatiotiships. — 
 These have been fully considered. 
 
 2. The intra-abdominal pressure. — This is the pressure 
 exerted by the intestines on the parietes. For practical 
 purposes it may be regarded as a fluid pressure — at right 
 angles to all parts affected by li. 
 
 3. The atmospheric pressure acting on the outer surface of 
 the body. 
 
 4. The results of alterations in posture. 
 
 When a fluid fills a cavity bounded by an expansile wall, 
 the condition of the latter is affected by the fluid pressure 
 which is everywhere at right angles to it, and also by the 
 action of gravity, which causes the weight of the fluid to 
 bulge the most dependent part of the sac. This is the case 
 to a certain extent in the abdomen and pelvis. 
 
 In the erect posture the pelvic floor is acted on by the 
 intra-abdominal pressure, and it is somewhat bulged down 
 by the action of gravity. There is also a slight increase in 
 the diameter of the abdomen just above the symphysis. 
 
 If the woman be placed on her head, a different state 
 7 
 
V. 
 
 98 
 
 THE PEL VIC FLOOR. 
 
 of matters is brought about. Increase of the abdominal 
 measurements takes place near the ribs, diminution above 
 the symphysis, and the outer surface of the pelvic floor 
 approaches somewhat to the bony pelvis. In this position, 
 atmospheric pressure and intra-abdominal pressure are un- 
 altered ; gravity is the cause of these changes, the intestines 
 tending to sink towards the diaphragm. 
 
 If the woman be placed in the genu-pectoral position the 
 same changes occur as in the latter case, though to a less 
 marked extent. 
 
 In the modified genu-pectoral or Sims' position the same 
 changes, still less marked, occur. 
 
 In the Trendelenburg posture, or in the lithotomy 
 posture with the hips well elevated, they are of the same 
 nature. 
 
 In these alterations it must be clearly understood that 
 no vacuum is caused in the peritoneal cavity. That is an 
 impossibility, because the abdominal and pelvic contents are 
 always in contact. It is only change in relationships that 
 is brought about. 
 
 In these movements no dilatation occurs in the passages 
 through the pelvic floor. They are kept closed by the 
 two forces acting on opposite sides of the floor, namely, 
 the intra-abdominal and atmospheric pressures, and, in the 
 erect posture, by the action of gravity as well. 
 
 If, when the woman is placed in the genu-pectoral 
 position, i.e. on her knees and chest, the hips being 
 elevated, the vagina be artificially opened, air rushes in 
 and distends it. Its walls elongate ; the uterus descends 
 nearer to the promontory ; the bladder is pushed partly 
 above the symphysis. In other words, as Simpson and 
 Hart have shown, the pubic and sacral segments of the 
 pelvic floor are separated, the former falling downwards 
 and forwards, the latter remaining unchanged save for a 
 slight recoil upwards. These changes are brought about 
 by the action of the atmospheric pressure in the vagina. 
 
 \ \ 
 
PHYSICS OF THE PELVIC FLOOR. 
 
 99 
 
 If the perineum be held back by a finger, and light be 
 reflected into the vagina, its walls and the vaginal portion 
 of the cervix can be seen. The same changes occur when 
 the woman is in the Sims' or semiprone position, and the 
 vagina opened up. 
 
 The rectum and bladder become distended like the 
 vagina, when air is admitted into them, the body being 
 placed in these positions or in the lithotomy position with 
 the hips well elevated. By the reflection of light into their 
 cavities, they can be thoroughly examined {pide p. 182). 
 
V 
 
 CHAPTER IV. 
 
 PUBERTY. 
 
 The transformation period from girlhood to womanhood is 
 characterised by the most profound changes in the con- 
 stitution. These are held to be of such importance among 
 most races in the world, that special regulations exist among 
 them for the care and management of girls at this critical era. 
 Some of these are of a most grotesque nature. In sc^me 
 African tribes, for instance, they are confined in huts and 
 not allowed to touch the ground for periods of considerable 
 length. In Borneo they are shut up for many months in 
 dark cells, cut off from all intercourse with the world. In 
 some parts of South America they are sewn up in ham- 
 mocks, and strictly dieted. In India a Hindoo girl remains 
 for days in a dark room, living on simple food. In many 
 countries the girls are beaten severely, cut with knives, or 
 exposed to the bites of insects, in order that a supposed 
 evil spirit, thought to be troubling them, may be driven out 
 of the body or allowed to escape. Though many of these 
 absurd habits are the result of primitive superstitions and 
 religious beliefs, it is interesting to note that they enjoin 
 simplicity and quietness of life while the girl is in the 
 transition period. 
 
 Systemic Changes at Puberty. 
 
 These are psychical and physical. 
 
 I. FsycMcal. — The character of the girl gradually 
 changes. Her tastes, which have hitherto been those of 
 
 _,./. 
 
SYSTEMIC CHANGES. 
 
 lOI 
 
 her young brothers, from whose general physical configura- 
 tion she did not greatly differ, now become greatly changed. 
 The romping, rollicking girl becomes shy and retiring ; new 
 desires and emotions take possession of her; womanly 
 characteristics apppear. Sex asserts itself. 
 
 2. Physical.— The breasts, pelvis, and neck enlarge ; 
 hair develops over the pubes and in tho armpits ; the voice 
 alters ; the angular, gawky girl develops into a creature of 
 graceful and symmetrical curves. The hitherto inactive 
 and incapable generative organs take on new activity. The 
 body of the uterus rapidly increases in size ; the ovaries 
 expel ripened ova — this feature usually develops shortly 
 before the other phenomena of puberty. A discharge of 
 blood takes place from the genital passage — the menstrual 
 flow. This occurs at intervals, and continues throughout 
 sexual life. 
 
 Age of Commencement of Puberty. 
 
 This varies considerably, and is influenced by different 
 factors. 
 
 1. Climate. — In warm countries it is earlier than in 
 cold ones. In the temperate regions it varies from 13 to 
 15. Thus, in Lapland, the age is about 18; in France 
 and England, about 15; in Southern Egypt and Sierra 
 Leone, 10. 
 
 2. Eaoe. — Racial influences are important. They tend to 
 be preser,^ed even under altered climatic conditions. Thus 
 in Jewesses the average age of commencement is the same 
 throughout the world. It is earlier than the age in 
 temperate regions. English girls in India preserve the 
 temperate European type. Africans in Europe retain their 
 own type. Race is probably, therefore, a more important 
 factor than climate. 
 
 3. Environment. — Puberty is earlier in city folk than in 
 country people. Luxury and rich living tend to hasten, 
 
^ ^wtf-', F,i-y'j 
 
 y 
 
 102 
 
 PUBERTY. 
 
 poverty to retard its onset. De Boismont found that in 
 Paris the average age among the poorest labouring classes 
 was 1 6 years, \\ months; among the well-to-do middle 
 asses, 15 years, 2 months. 
 
 4. Sexual stimulation. — It is widely believed that too 
 early stimulation of the sexual instincts leads to a premature 
 establishment of puberty. It is difficult to prove this, how- 
 ever. Many cases cited are no doubt those in which 
 puberty and sexual instinct have been early developed. 
 
 5. Heredity. — In some families peculiarities may be 
 transmitted from generation to generation, e.g. abnormally 
 early development. 
 
 6. Individuality. — Statements are made regarding the in- 
 fluence of size, build, complexion, etc., on the onset of 
 puberty, but these are not at all reliable. • 
 
 Prematurity of Puberty. 
 
 In some cases all the physical signs of puberty, e.g. 
 changes in breasts, general contour, menstrual flow, etc., 
 may develop very early. A few cases are on record where 
 they were noted before the age of 5. In ohe or two 
 instances children have been born with all the marks of 
 puberty i{oide p. 665). In some cases menstruation may 
 occur with few or none of the other signs. In other cases 
 may be found the development of hair and breasts, without 
 change in bodily contour or without menstruation. 
 
 We do not know what changes occur in the internal 
 genitals in all these early cases. It is certain that preg- 
 nancy has taken place at the early age of 9. We do 
 know that in some cases ova may be shed at a very early 
 period, and that the uterus may develop prematurely. 
 
 We are not certain as to the relation of pathological conditions to the 
 early appearance of puberty. In several cases where post-mortem 
 examinations have been made, various conditions have been found, e.g. 
 cystic ovary, sarcoma of the ovary, hydrocephalus, rickets. 
 
ONSET OF MENSTRUATION. 
 
 103 
 
 In several cases, however, no abnormal conditions have 
 been found. 
 
 Delayed Puberty. 
 
 Sometimes puberty may be delayed in all its manifesta- 
 tions as late as the age of 25. Many variations are found, 
 however, as regards the various phenomena. Sometimes 
 all may be present, save menstruation. It is important to 
 bear in mind that delay may be caused by pathological 
 conditions, e.g. anaemia. 
 
 First Onset of Menstruation. 
 
 Sometimes the first menstrual discharge appears sud- 
 denly, lasts for a few days, then stops, and reappears after 
 an interval of three or four weeks, when the duration and 
 quantity of the flow are the same as at first ; in other 
 words, the menstrual type and habit may be established at 
 once. Uusually, it is a gradual process. Thus, the only 
 indications may be a feeling of fulness, hea , or pain in the 
 pelvis ; chills or flushes of heat in different parts of the 
 body. The girl may feel drowsy or irritable, may suffer 
 from headache and neuralgia, may lose her appetite, and 
 may have disordered stomach and bowels. There may be 
 swelling and tenderness in the breasts, and some white 
 mucous discharge from the vagina. 
 
 These symptoms may occur at regular or irregular periods 
 before any discharge of blood occurs, and may take place 
 in small amounts, gradually increasing at successive periods 
 until the permanent habit is fixed. 
 
 In some cases there may be a discharge of blood at the 
 first period and none afterwards for several months. In 
 other words, menstruation may be established gradually, 
 intermittently, or suddenly. 
 
 It must be remembered that certain pathological states 
 
V, 
 
 104 
 
 PUBERTY. 
 
 cause many of the disturbances found in connection with 
 the onset of puberty. 
 
 Relation of Puberty to Nubility. 
 
 Though the reproductive Ufe begins with puberty, the 
 girl is not then fitted for marriage. Womanhood is reached 
 only after years of slow and gradual growth. In the tem- 
 perate regions of the world, there can be no doubt that the 
 ripened condition of maturity is not reached before the age 
 of 20 or 21. It is only then that the standard of develop- 
 ment is reached which is compatible with the most success- 
 ful bearing of the grave responsibilities of wifehood and 
 motherhood. The too early exercise of the reproductive 
 function leads to increased suffering on the part of the 
 mother, depresses her vitality, and increases her liability 
 to disease. 
 
 Bertillon's figures show the chances of death are much 
 greater when girls marry below 20. 
 
 The offspring are apt to be ill-developed, and die in 
 large numbers in early life ; only a small percentage live 
 long and robust lives. 
 
 Breeders of animals know well that the union of Im- 
 mature parents produces a feeble or stunted progeny. 
 Dogs thus born are delicate, and are usually killed by 
 the distemper. 
 
 Many dog-raisers destroy the first litter of a bitch even 
 if she be nubile, because they have observed that the first 
 puppies are rarely of the best quality. It was noted by 
 Aristotle that the Greeks who married very early had 
 small and weakly children. 
 
 In France, it has been observed that when fear of the 
 conscription has caused many young people to marry, the 
 offspring were small and lacking in vigour. 
 
 Among the offspring of immature parents there is a 
 larger proportion of idiots, cripples, criminals, scrofulous. 
 
RELATION TO NUBILITY, 
 
 105 
 
 insane, and tubercular than among children of nubile 
 parents. 
 
 Disorders of Puherty. 
 
 Besides the normal disturbances which I have described, 
 there are certain conditions, more or less grave in nature, 
 which are apt to be developed in connection with this 
 period. 
 
 Amenorrhaa is common. — It may be manifested either 
 by a delay in the appearance of menstruation after the 
 other signs of puberty have developed, or in the diminution 
 or cessation of the menses after they have been established. 
 Anaemia is present in the great majority of these cases, and 
 is undoubtedly the cause of the amenorrhoea. The causes 
 of the anaemia are not clear in all instances, but, in many 
 cases, they are — over-work and imperfect nutrition among 
 the poor, over-study and insufficient or irregular exercise 
 among the well-to-do. 
 
 In some cases, the amenorrhoea may be due to some 
 general disease, which has reduced the general health. In 
 other cases, it may be due to some local pelvic trouble, 
 such as atresia of some part of the genital tract. 
 
 In some cases it may be due to an abnormal rate of 
 physical development. 
 
 Slight attacks of mental and nervous derangement are 
 not uncommon, especially where there is some predisposi- 
 tion to neuroses ; these are most apt to be marked where 
 the general health and nutrition are poor (Clouston). 
 These conditions may afterwards pass into insanity ; but 
 it is to be noted that the gravest forms of insanity are 
 rarely developed at the period of puberty. Clouston points 
 out that the chief neuroses met with in the pre-pubescent 
 period, namely, from 7 to 14, are mainly chorea, somnam- 
 bulism, asthma, megrim, some eye defects, fnd some 
 amount of epilepsy ; in the period from 14 to 25, epilepsy, 
 hysteria, adolescent insanity, instinctive immorality, arrested 
 
tflf 
 
 PUBERTY. 
 
 body growth, ugliness, joint disease, ingrowing nail, acne, 
 many skin diseases, many forms of impaired vision, barren- 
 ness, and perhaps phthisis and acute rheumatism. 
 
 <ii 
 
 MENSTRUATION. 
 
 When thoroughly established, menstruation may be 
 described as a cyclical change, with general disturbances, 
 and marked by local (pelvic) phenomena, not yet definitely 
 known, of which the most evident is the loss of blood from 
 the cavity of the corpus uteri. 
 
 General phenomena. — Different general symptoms are 
 found in women. Great variations are found as regards 
 the degree in which they are present. It is hard to 
 determine to what extent women are affected, owing to 
 the marked differences in their nervous organisations. 
 Some feel acutely distresses of which others scarcely com- 
 plain. The following symptoms are met with ; — Nervous 
 and gastric disturbances, tenderness or swelling in the 
 breasts, sensations of heat and cold, torpor or over- 
 sensitiveness, fulness of neck, pain or throbbing in head 
 and neck. Many women have none of these whatever. 
 
 Just before the flow, the urea excretion reaches the 
 maximum ; afterwards, the minimum. The temperature 
 rises half a degree above the average before the period, 
 falls during the flow, and goes down to half a degree below 
 the average immediately after the period. The pulse rate 
 and arterial tension run a corresponding course. 
 
 Locally, there is a feeling of weight and fulness in the 
 pelvis, irritability about the bladder, discomfort about the 
 local parts, tenderness or pain in the lower part of the 
 belly, and bearing-down in the back. 
 
 Local pelvic phenomena. — The outer surface of the ex- 
 ternal genitals becomes more oily, there is an increased flow of 
 mucus from the vagina, often associated with a peculiar pene- 
 trating odour. This period is often called the invasion stage. 
 
 (V 
 
MENSTRUATION. 
 
 107 
 
 i< 
 
 Then the mucus becomes tinged with blood, and soon 
 the full bloody discharge is established. This lasts for a 
 varying number of days, and is known as the persistence 
 stage. 
 
 Gradually, the discharge becomes paler in colour, but 
 very turbid. It soon clears up, and there is left only the 
 secretions of mucus. This is the stage of decline. Normally, 
 no clots occur in the discharge. 
 
 Physical changes in the pelvis. 
 
 1. There is general congestion of the viscera. 
 
 2. In the P'allopian tubes there is only congestion, no 
 change being recognisable in the mucosa. 
 
 3. In the ovaries, ovulation may or may not be found 
 to have recently occurred, or to be in progress. It is not 
 an essential feature. 
 
 4. In the uterus. 
 
 As regards the uterus, there has been much dispute. 
 We are not yet in possession of sufficient facts to warrant 
 a complete account of the changes which are found. It 
 may be definitely stated, however, that they are limited to 
 the mucosa of the corpus uteri. Before the onset of 
 menstruation the whole uterus is enlarged and firm. When 
 the flow begins it gets softer and relaxed, and the cervical 
 canal dilates somewhat during the first three or four days. 
 For a considerable time the view of Williams has held 
 ground, namely, that owing to haemorrhages into the mucosa 
 and to its fatty degeneration, it is entirely shed as deeply as 
 the uterine musculature. As this view was based upon a 
 study of uteri from post-mortems made in cases of acute 
 febrile conditions, it cannot be accepted. 
 
 Bland Sutton, Johnstone, and Minot have examined 
 fresh uteri during and at the end of menstruation, and have 
 found that only small, superficial portions of the lining 
 epithelium were shed. At first the mucosa swells owing 
 to the dilatation of blood vessels, especially the capillaries. 
 Some of the most superficial capillaries rupture, and the 
 
io8 
 
 PUBERTY. 
 
 blood escapes among the stroma and into the uterine 
 cavity. Further than this we cannot go at present. There 
 is no proof that fatty degeneration occurs normally. 
 
 Researches on monkeys may be referred to in this con- 
 nection. The most elaborate have been carried out by 
 Heape, who examined many uteri in various stages of 
 menstruation in the case of Semnopithccus ente/ius, whose 
 menstrual type is a four-week one, the duration of the 
 period being four days. He found congestion and 
 haemorrhages, with the shedding of portions of the lining 
 epithelium, along with small bits of sub-epithelial stroma. 
 
 Bland Sutton has also carefully examined menstruating 
 uteri in macaque monkeys, and baboons, and found only 
 congestion and loss of blood, without even shedding of 
 epithelium. 
 
 Menstraal type. — By this term is meant the periodicity 
 of the process. In about 86 per cent, of women the type 
 is regular^ i.e. menstruation occurs at regular intervals. It 
 is calculated in terms of the number of days from the 
 beginning of one period to the beginning of the next. The 
 most common is the 28-day type, viz. in about 71 per cent, 
 of cases. In 14 per cent, it is the 30-day type. In some 
 cases the 21 -day type is found, and a few others occur. 
 
 In a certain percentage of cases the type is irregular, the 
 women being perfectly healthy. Such a case is one known 
 to me, in which there was a mixture of 21, 25, and 28 day 
 types. 
 
 Menstrual habit. — By this term is meant the duration 
 and quantity of the flow. Normally, considerable varia- 
 tions are found. Thus it may last from two to eight days ; 
 occasionally for nine days. A large number of women 
 have a discharge of blood for a week ; many for three or 
 four days. In health, the amount lost is generally about the 
 same in succeeding periods. It is difficult to estimate the 
 amount accurately ; the average amount is said to be from 
 6 to 8 oz. Estimation by means of diapers is unreliable. 
 
 \\ 
 
THE CUMACTERIC. 
 
 109 
 
 Very rarely healthy women are found who lose blood for 
 less than two days or for more than eight. These extreme 
 cases are mostly pathological. 
 
 Physiological absence of menstruation. — Menstruation 
 is absent normally before puberty, in the intervals between 
 the irregular discharges common during the establishment 
 of the menstrual function at puberty, during pregnancy and 
 lactation, in the intervals oi' the " dodging-period " at the 
 change of life, and after the menopause. 
 
 Sometimes, from various causes {^nde p. 1:9), there may 
 be a discharge of blood from the vagina during pregnancy 
 or lactation. 
 
 ViCiirious menstruation. — For a long period it has been 
 believed that a discharge of blood, of the nature of the 
 menstrual flow, may take place from parts of the body other 
 than the mucosa of the corpus uteri in certain cases. Gould 
 and Tyle have recently collected a number of these. These 
 discharges may occur regularly or irregularly, and usually 
 occur v/hen the regular menstrual flow ceases or becomes 
 irregular. It is very likely that in some instances the 
 haemorrhages are due to some pathological cause, e.^. pur- 
 pura. At anyrate, the phenomenon is a very rare one. 
 
 The discharge has been described as taking place from 
 wounds and sores of the skin ; from various parts of the 
 normal skin, as a kind of bloody sweat ; from the eyes, 
 nose, mouth, ear ; from the breasts. It has also been 
 reported as coming from the bladder and rectum. 
 
 THE CLIMACTERIC. 
 
 One of the most important periods in a woman's life is 
 that which is marked by the cessation of sexual activity. 
 Various terms are employed in addition to the one above 
 used, e.g. "the change of life," "critical time," "turn of 
 life," "menopause." 
 
 The phenomena met with at this period are so varied in 
 
no 
 
 PUBERTY. 
 
 character, the changes in the whole system of the woman 
 are so profound, and the distinction between the normal 
 and the pathological is so ill-defined, that the student 
 should give the most thorough attention to the whole range 
 of signs and symptoms which occur, not only for their 
 scientific interest, but because of their great importance 
 in relation to the practice of medicine. The greatest 
 blunders are made continually by physicians as a result of 
 careless observation and inattention regarding this period 
 of a woman's life. What is natural may be treated as 
 disease, and, on the other hand, pathological processes 
 may be overlooked because the symptoms produced by 
 them are thought to be merely phenomena of the meno- 
 pause. 
 
 The age at which the climacteric occvirs varies greatly, the 
 range of variation being more marked than in the case of 
 the development of puberty. In temperate regions it takes 
 place in about 50 per cent, of women between 45 and 50 ; 
 in 25 per cent, between 40 and 45; in \2\ per cent, 
 between 35 and 40 ; in \2\ per cent, between 50 and 55. 
 In some cases the menopause may develop prematurely, 
 e.g. under 30, or may be abnormally late in appearing. It 
 is impossible to state accurately what is the essential factor 
 in inducing the climacteric, and what marks the limits of its 
 duration. It is rarely quickly established, generally the 
 phenomena which characterise it being en evidence for an 
 extent of from one to three years. 
 
 The factors determining the appearance of the change of 
 life are not well understood. It is usually later in cold than 
 in hot climates. It is believed to be earlier in the hard- 
 working and poor than in the luxurious and rich. Racial 
 peculiarities are found, e.g. the Jews show the same tend- 
 ency to early menopause in all parts of the world. The 
 relation to the onset of puberty is not clearly known. It is 
 stated by some that there is no special law of relationship ; 
 by others it is believed that when puberty appears early the 
 
THE CLIMACTERIC. 
 
 Ill 
 
 menopause will also be early ; others think that the earlier 
 menstruation appears the later it ceases. 
 
 Structural changes in the body. — Atrophy of the ovaries 
 occurs, the Graafian follicles gradually becoming destroyed 
 (? by fatty degeneration of the cells), and the connective 
 tissue elements becoming more fibrous. They get harder, 
 smaller, and irregular. These changes may take place 
 quickly or they may be prolonged over years. There can 
 be no doubt that their functional activity may continue in 
 some cases long after menstruation has ceased, for preg- 
 nancy may take place at that time. 
 
 The uterus becomes smaller and its walls thinner. The 
 cervix gets shortened, and may remain hard or flabby. The 
 mucosa thins, the glands getting gradually obliterated and 
 fibrous tissue developing. The lining epithelium becomes 
 flattened and, in parts, destroyed. Adhesions may take 
 place between opposed mucous surfaces. 
 
 The vagina becomes gradually contracted, especially in 
 its upper part, and often assumes a conical shape. The 
 rugre gradually disappear. At first its walls are congested, 
 and then, as its vessels atrophy in places, it has an irregu- 
 larly mottled appearance. Afterwards it gets quite pale. 
 
 The Fallopian tubes atrophy, and the lumen gets often 
 more or less obliterated. The external genitals gradually 
 lose their fat, the labia becoming thin folds of skin. The 
 introitus va<rin3e becomes narrowed. The connective tissue 
 elements become tougher and less capable of being stretched 
 than in early life. 
 
 The body-contour alters somewhat. It may become less 
 graceful, owing either to disappearance of fat or to great 
 deposition of fat. Sometimes it becomes somewhat mascu- 
 line in type ; the skin may get coarser, and hairs may 
 develop on the chin. The milk glands atrophy, and the 
 breasts may be changed to thin flabby masses, but if the 
 body takes on fat they may become full and large. There 
 is generally less activity in the blood-forming tissues, some 
 
v>. 
 
 112 
 
 PUBERTY. 
 
 of which shrink and harden. *' Life becomes slower," as 
 one author expresses it. 
 
 Menstruation comes to an end. This occurs in a variety 
 of ways. In some cases the intervals between the periods 
 lengthen ; in others they are shortened. The flow may 
 increase in quantity or duration, or in both ; it may be 
 diminished ; or it may be irregularly greater or less, often 
 alternating in quantity. Between the periods there may 
 be small occasional losses of blood, continued dribbling, 
 or sudden large losses. Sometimes menstruation may sud- 
 denly come to an end. In other cases it may gradually 
 diminish and cease. In most cases the above-noted irre- 
 gularities occur, the name " dodging-period " being given 
 to the time in which the menstruation occurs at irregular 
 intervals. 
 
 General phenomena. — The greatest variations are found 
 as regards the general phenomena met with at the meno- 
 pause. 
 
 In a few cases the woman may present no peculiarities 
 whatever to distinguish her from what has been considered 
 as her normal habit. In the great majority of instances, 
 however, marked characteristics are developed, which may 
 be noticeable not only to the woman, but to her friends and 
 physician. Changes may be brought about which affect all 
 the functions of the nervous system, e.g. mental, motor, 
 sensory, co-ordinating, etc. Generally, she feels less in- 
 clined to indulge in her past activities. She is more easily 
 bored and worried. Sometimes her tastes and disposition 
 may entirely change. A vivacious and impulsive nature 
 may become calm and melancholy, or a quiet, subdued 
 nature may develop a tendency to irritability and im- 
 patience. Often the power of concentration of the attention 
 is greatly lessened, and there may be forebodings of sickness, 
 disaster, etc. 
 
 Some women suffer from a feeling of heaviness in the 
 head ; they may be dull and stupid, and inclined to sleep. 
 
THE CLIMACTERIC. 
 
 lU 
 
 Sometimes a condition of stupor may last for hours. Loss 
 of memory is often met with, and the woman may forget 
 the names of those very dear to her. 
 
 There may be an abandonment of self-control or a fear 
 that it will be lost. A woman may lose all interest in those 
 she loves, and may even try to harm them, or she may be 
 suspicious that they wish to injure her. Sometimes suicidal 
 and homicidal tendencies are induced, but they are not 
 strongly marked. There may be developed perversion of 
 tastes ; thus a woman who has always been temperate may 
 be filled with a keen desire to drink alcoholic liquors. 
 
 Forced ideas may develop, in varyiiig degrees of intensity 
 and for shorter or longer lengths of time. Thus a woman 
 may believe that she is to lose her reason, that she has a 
 tumour. Or they may be of the nature of such a case as 
 that reported by Borner, in which a woman believed that 
 something was wrong with her bladder. She always took a 
 seat near the door at a public entertainment, in order that 
 she might retire easily if the desire to urinate should seize 
 her. (iradually she gave up going out of her house alto- 
 gether, from fear of not being able to hold her water. 
 
 The changes in disposition may be manifested inter- 
 mittently or continuously. Thus, when ill-temper develops, 
 it may exhibit itself in an occasional outburst, or continuously. 
 Changes may be found in the sexual relationships. 
 
 The former vivid consciousness of sex differentiation be- 
 comes less marked. The influence of one sex on the other 
 is less keen and subtle. 
 
 The sexual appetite very often disappears more or less 
 completely, and suddenly or gradually \ and, as Clouston 
 says, "with it the affectiveness changes in its object and 
 greatest intensity from the mate to the progeny, losing its 
 imaginative force, its fire, and its impulsiveness." Some- 
 times sexual desire is abnormally intensified, and may have 
 distressing results ; this may be merely due to a condition 
 of hyperesthesia, or may be associated with a pathological 
 8 
 
114 
 
 PUBERTY. 
 
 condition, such as tumour. This intensification may occa- 
 sionally last long after the menopause. 
 
 Many peculiarities are found in connection with the 
 sensory part of the nervous system. In some cases there 
 is marked sensitiveness to bright lights, to loud noises, or 
 to strong smells. There may be impairment in the power 
 of determining the nature of impressions. Thus sour things 
 may be considered sweet, or sweet things sour, and well- 
 known smells may be entirely mistaken. Sometimes women 
 complain of having bad tastes, of hearing strange noises, 
 of deafness, of dimness of vision. 
 
 On the skin there may be areas of anaesthesia or hyper- 
 aesthesia; sometimes, a feeling as if the skin were being 
 pricked with needles. Plushings or " heats " are often met 
 with. They may affect one or more parts of the body, very 
 often the head. They are usually most marked in nervous 
 women, and are increased by emotional excitement, shock, 
 great warmth, and other factors. Sometimes there may be 
 considerable weakness or faintness r'uring one of these 
 heat spells. 
 
 Chills may alternate with the flushings. Sweating may 
 also be a marked phenomenon. It may occur at irregular 
 intervals, affecting one or other part of the body. Often 
 one part tends to be specially affected. Sometimes it is 
 worst at night ; sometimes after exertion or emotion. It 
 may occur along with the flushing or independent of it. 
 Itchiness may occur in different parts, but especially on 
 the external genitals. It may vary greatly from time to 
 time as regards its extent and location, and it may occur 
 only at intervals. 
 
 Pains may be felt in various parts, e.g. headache, sciatica, 
 neuralgia, megrim. In some cases, a woman who has 
 suffered in her past life from these conditions may be cured 
 by the menopause. 
 
 Sometimes the chest or belly is the special seat of pain. 
 Attacks like angina pectoris may develop. Palpitation of 
 
 \\ 
 
THE CLIMACTERIC. 
 
 "5 
 
 It 
 
 it. 
 
 on 
 
 to 
 
 in. 
 of 
 
 the heart may be very troublesome. There may be a 
 tendency t) faintness and vertigo. Disturbances of the 
 alimentary tract are common. If a woman has suffered 
 from these in the past she generally complains more at the 
 menopause, though, sometimes, improvement sets in then. 
 
 Cramps may occur in various parts of the body. These 
 may affect the throat, interfering with speaking or swallow- 
 ing. There may be stiffness or weakness in joints and 
 muscles. In some cases, well-marked hysterical convulsions 
 take place. True epilepsy may develop, though probably 
 only in those with some hereditary taint, or in whom it 
 had occurred in early life. 
 
 It is very evident from the consideration of the above- 
 mentioned phenomena, that they may be regarded as falling 
 under the heading of " neuroses." What the essential 
 change is that brings about the altered condition of nervous 
 stability, we do not know ; probably it is related to meta- 
 bolic changes {vide p. 668). 
 
 There can be no doubt that the symptoms are aggravated 
 by various organic disturbances, which may exist at the 
 time of the menopause. Ansemia, for instance, is very 
 common, and may have a marked influence in determining 
 certain distressing symptoms. Stomachic, pelvic, or other 
 diseases may exist. 
 
 The menopause in relation to special diseases. — I have 
 already pointed out how certain mental diseases and epilepsy 
 may be induced at this period. Certain skin affections may 
 develop, especially acne, herpes zoster, eczema, urticaria, 
 pruritus ; the latter is in some cases due to actual changes 
 in peripheral nerves or end organs. Kraurosis vulvae is 
 often found. Disturbances of the alimentary tract resulting 
 in vomiting, heartburn, constipation, etc., may be induced ; 
 pre-existing troubles may be intensified. Sometimes they 
 may improve or disappear. 
 
 It is important to note that the menorrhagia and metror- 
 rhagia, which I have described, may be aggravated by the 
 
ii6 
 
 PUBERTY. 
 
 existence of such conditions as inflammations in the pelvis, 
 subinvolution of the uterus, displacements of the uterus, 
 new growths of that organ. It is, therefore, very important 
 that these conditions should not be overlooked. Fibroids 
 are very common causes of bad bleedings at the menopause. 
 Carcinoma of the cervix is most frequent about this period. 
 Newman has analysed 500 cases of disease after the 
 climacteric had been established a year or more. The 
 following table gives his results : — 
 
 Disease. 
 
 With H-«morrhage. 
 
 Without H/Cmorrhage. 
 
 
 
 Age at 
 
 
 
 
 
 No 
 
 Average 
 
 which 
 
 No 
 
 Average 
 
 Year of 
 
 
 
 Age. 
 
 Menopause 
 
 
 Age. 
 
 Menopause. 
 
 
 100 
 
 
 occurred. 
 
 
 
 
 Carcinoma cervicis 
 
 56.2 
 
 47.7 
 
 3 
 
 703 
 
 48 
 
 uteri 
 
 
 
 
 
 
 
 Prolapse of vag- 
 
 24 
 
 59 
 
 43-6 
 
 88 
 
 59.2 
 
 47.6 
 
 ina or uterus 
 
 
 
 
 
 
 
 Carcinoma cor- 
 
 18 
 
 57-4 
 
 49.5 
 
 
 
 
 poris uterus 
 
 
 
 
 
 
 
 Mucous polypus 
 
 8 
 
 55-4 
 
 47.25 
 
 
 ... 
 
 . • • 
 
 of uterus 
 
 
 
 
 
 
 
 Senile changes in 
 
 5 
 
 63.6 
 
 49.4 
 
 80 
 
 54.2 
 
 46.7 
 
 genitals 
 
 
 
 
 
 
 
 1 Myoma uteri 
 
 4 
 
 68 
 
 51.3 
 
 10 
 
 53-3 
 
 49.4 
 
 i Ovarian cyst 
 
 4 
 
 54 
 
 45-5 
 
 21 
 
 58.2 
 
 47.7 
 
 Doubtful condi- 
 
 20 
 
 61.7 
 
 47.4 
 
 20 
 
 58.5 
 
 46.1 
 
 tions 
 
 
 
 
 
 
 
 Displacements 
 
 
 • •• 
 
 ..* 
 
 35 
 
 49.2 
 
 47.5 
 
 and inflamma- 
 
 
 
 
 
 
 
 tions of uterus 
 
 
 
 
 
 
 
 Other afiections 
 
 • * * 
 
 ... 
 
 • • t 
 
 60 
 
 58.8 
 
 44.8 
 
 of genitals 
 
 183 
 
 56.5 
 
 
 317 
 
 
 
 46.5 
 
 56.1 
 
 46.9 
 
 It thus appears that out of these 500 cases, 183, or 36I 
 per cent., had a return of haemorrhage after the menopause 
 had been established a year or more. Of these, cancer 
 caused the bleeding in 54 per cent, of the cases. 
 
 The question of early climacteric. — It is generally 
 
 \\ 
 
DISTURBANCES OF MENSTRUATION. 
 
 "7 
 
 believed that very few cases of premature establishment 
 of the menopause occur under normal conditions, but 
 that most are pathological in nature, being due to such 
 conditions as the following :- Sudden shock, great anxiety, 
 extreme exhaustion, severe cold, tuberculosis, exanthemata, 
 septicaemia ; various poisons— <'.^(,''. alcohol, opium, phos- 
 phorus, arsenic, mercury ; inflammation of the uterus and 
 appendages, new growths in the ovaries. 
 
 It is impossible, however, to speak with any accuracy 
 regarding the influence of these various conditions. The 
 metabolism of the body may be profoundly altered by 
 some general influence on the nervous system, or reflexly 
 through local irritation, e.g. inflammatory changes in the 
 ovaries. 
 
 Delayed climacteric. — As I have already stated, there is 
 undoubtedly evidence that sexual activity may be prolonged 
 for years beyond the normal period. Menstruation may 
 or may not be present, but ovulation may continue, and 
 conception may take place {vide p. 657). 
 
 Many cases described as protracted climacteric are only 
 cases in which pathological haemorrhages take place. 
 These may be due to the heart lesions, to uterine fibroids, 
 carcinoma, sarcoma, adenoma, polypus, erosions of the 
 vaginal portion of the cervix and of the vaginal walls. 
 
 DISTURBANCES OF MENSTRUATION. 
 Amenorrhcea. 
 
 Amenorrhoea means diminution or cessation of the 
 menstrual flow. I have already referred to its occurrence 
 in connection with the development of puberty {^ide p. 105). 
 
 In the adult state, it is due to all conditions in which the 
 health is reduced, e.g. anaemia, Bright's disease, malaria, 
 phthisis, fevers, etc. It may be due to sudden shock, to 
 great nervous depression, to chills. It may result from 
 a change of life ; this is often found in girls who go 
 
ii8 
 
 PUBERTY. 
 
 from the country to the city to work ; sometimes in 
 those who go away to study ; sometimes in those who 
 go on a long sea voyage. It may be due to develop- 
 mental defects, t\j^. absence or rudimentary condition 
 of the internal genitals ; it may result from atresia in 
 the genital tract preventing the escape of the menstrual 
 blood ; it may be due to cretinism ; it may be caused 
 by various pelvic diseases. In most of these it probably 
 results from the action of the diseases in reducing the 
 patient's health. It may be found in parametritis chronica 
 atrophicans. It may accompany the anremia succeeding 
 a bad hsematocele. It may be found in bad cases of 
 tubal disease, e.g. pyosalpinx, where the patient is much 
 run down. It may follow acute inflammation, e.i:^. in 
 the exanthemata where the ovaries have been destroyed ; 
 or it may be due to gradual cicatrisation and atrophy of 
 the ovaries from chronic inflammation in and around them, 
 or from abscess formation. In tumours of the ovaries it 
 may only be present as a result of the local condition, 
 if the disease be bilateral and advanced. 
 
 It may be found in connection with an endometritis, 
 where the haemorrhagic or leucorrhoeal discharge has 
 greatly weakened the patient, or with old inflammation, 
 where the mucosa has been changed to fibrous tissue. It 
 is found in superinvolution of the uterus. In vesico-vaginal 
 or recto-vaginal fistulce it may be brought about. It is 
 found after removal of the ovaries {^ide p. 654). According 
 to Lawson Tait it follows removal of the tubes alone i^ide 
 P- 655). 
 
 it is important, also, to emphasise the necessity of 
 bearing in mind the periods of normal and physiological 
 amenorrhoea, i.e. the period before puberty, the times 
 between the irregular discharges so common in many cases 
 at the establishment of the menstrual function, the months 
 of pregnancy, the time of lactation (though in some cases 
 menstruation may occur during nursing), the intervals of 
 
DISTURBANCES OF MENSTRUATION. 
 
 119 
 
 the " dodging-period " at the change of life, and the period 
 after the menopause. Another essential point must be 
 attended to in this relationship, namely, the difificulties in 
 the determination of pregnancy from the menstrual history. 
 It is most important that the student should attend to 
 these. Normally, when a woman becomes pregnant, her 
 menstruation ceases, and it is customary to estimate the 
 duration of pregnancy from her last period. Moreover, 
 the history of the stoppage of menstruation in a woman 
 should always suggest the possibility of pregnancy, par- 
 ticularly in a married woman. The student must bear in 
 mind that a girl may become pregnant before she ha*; ever 
 begun to menstruate, that a woman may sometimes b come 
 pregnant during a period of amenorrhoea from some diseased 
 condition, that it may occur during lactation and during 
 the " dodging-period " of the menopause. 
 
 Further, irregularity of menstruation may interfere with 
 correct calculation of pregnancy. Another set of cases 
 present difficulty, namely, those in which discharge of blood 
 may take place during pregnancy, e.g. in ectopic gestation, 
 in pregnancy in one-half of a septate or bicornuate uterus, 
 and in certain abnormal or diseased conditions. 
 
 If these important points be forgotten, serious error may 
 be committed, e.g. a woman during the menopause, suffer- 
 ing from dyspepsia and flatulence, with a history of eleven 
 months' amenorrhoea, was sent to hospital as a case of 
 spurious pregnancy, whereas an actual pregnancy of four 
 months' duration was found in her. A sound has been 
 passed into the uterus of a woman during lactation, and 
 an abortion caused ; as the patient was nursing, it was 
 not supposed that she would be pregnant, and a careless 
 examination was made. 
 
 Menorrhagia — Metrorrhagia. 
 
 Menorrhagia means increased flow of blood from the 
 uterus at the menstrual period, and may be expressed 
 
120 
 
 PUBERTY. 
 
 
 in terms of quantity or duration, or of both. The normal 
 variations found in women must be borne in mind. What 
 is abnormal for one may be normal for another. 
 
 Metrorrhagia means haemorrhage from the uterus at 
 times other than the menstrual periods. In this con- 
 nection must be remembered the irregular discharges of 
 blood often found during the period of puberty before 
 menstruation is well established, and also during the period of 
 the menopause. The irregularity of type in certain women 
 in a state of health must also be borne in mind. These 
 two conditions may occur together or independently. 
 
 In this section attention is given chiefly to their occur- 
 ence in the non-pregnant woman. They may be caused 
 by various general disturbances and non-pelvic disease^, 
 e.g. haemophilia, scorbutus, acute specific fevers, Bright's 
 disease, cirrhosis of the liver, heart disease, alcoholism. 
 
 Various pelvic diseases may lead to their occurrence, e.g. 
 pelvic peritonitis ', haematocele and hoematoma ; salpingitis, 
 ovaritis, especially in early stages ; ovarian tumour in some 
 cases ; endometritis, endocervicitis, metritis, though not in 
 advanced cases ; retroversion and retroflexion of the uterus ; 
 inversion of the uterus ; fibromyoma, sarcoma, carcinoma, 
 polypus of the uterus, prolapsus uteri, subinvolution. 
 Postclimacteric menorrhagia is referred to on p. ii6. 
 
 The following conditions may lead to a discharge of 
 blood which may be mistaken for menorrhagia or metror- 
 rhagia, namely, lesions of the vagina and vulva, e.g. ulcera- 
 tion, tumours. 
 
 It must be remembered, also, that certain states con- 
 nected with pregnancy may lead to haemorrhages from 
 the uterus, e.g. incomplete abortion, retention of bits of 
 placenta or membranes, placenta praevia, hydatid mole, 
 accidental haemorrhage, inertia of the uterus. 
 
 Halliday Croom and other authors mention the occurrence 
 of " idiopathic menorrhagia " where no cause, whatever, can 
 be found. 
 
DISTURBANCES OF MENSTRUATION. 
 
 121 
 
 Dysmenorrhcea. 
 
 By this term is meant pain associated with menstruation. 
 In normal conditions usually no pain is felt ; in a number 
 of these cases only slight pelvic discomfort ; and in others 
 only a dull backache. When there is distinct pain it is 
 sharp, dull, dragging, down-bearing, or labour-like. It may 
 be felt in the loins, in the small of the back, in the pelvis ; 
 and from these regions may radiate into the thighs. Great 
 variations are found as regards the time of onset and the 
 duration of the pain. Thus it may be felt only for a day 
 or two preceding the menstrual flow, ceasing at the com- 
 mencement ; for a day or two before, as well as for the 
 first day or two of the flow ; during the first day or two of 
 the flow only ; during the whole extent of the flow ; during 
 the last two or three days ; during the day or two succeeding 
 the flow. 
 
 At present we cannot satisfactorily distinguish the factors 
 which determine these variations. The pain varies greatly 
 in intensity. It may in no way interfere with the woman's 
 regular life, or it may entirely incapacitate her for her 
 duties. 
 
 Before considering the conditions in which dysmenorrhcea 
 occurs, it is well shortly to recapitulate the physical factors 
 in the pelvic phenomena of normal menstruation, so far as 
 we know them. 
 
 1. According to Lindblom, the uterus enlarges slightly 
 prior to the menstrual flow, and during the period is felt 
 to be somewhat soft and lax, continuing so for a short time 
 after the bleeding stops. The mucosa becomes congested 
 and swollen. 
 
 2. Herman has shown that some widening of the cer- 
 vical canal occurs during the flow, reaching its maximum 
 on the third or fourth day. The widening is not at ail 
 proportionate to the quantity of blood lost. 
 
 3. The chief loss is in blood, small portions O: iy of the 
 
V 
 
 122 
 
 PUBERTY. 
 
 epithelial covering of the mucosa being shed, and possibly 
 very minute bits of the sub-epithelial connective tissue stroma. 
 'I'he blood does not clot in the uterus in normal conditions, 
 owing to the alkaline reaction of the uterine mucus, which 
 is abundantly poured forth during the period, and owing to 
 the continual passage outwards of the flow. 
 
 4. There is general congestion of the pelvic viscera. 
 
 5. Ovulation is not an essential part of the process, and 
 may or may not accompany it. 
 
 Dysmenorrhoea is found in two sets of conditions : — 
 
 1. Associated with various pathological or abnormal con- 
 ditions in the pelvis, recognisable on physical examination. 
 
 2. When no pelvic lesions, or only slight ones, can be 
 made out. 
 
 I I 
 
 I. 
 
 -In Relation to Changes in the Pelvis recognisable on 
 Physical Exa?nination. 
 
 1. Associated with chronic pelvic peritonitis and cellu- 
 litis. — These varieties of pelvic inflammations are related 
 to dysmenorrhcea in the following ways : In some cases 
 there is no dysmenorrhoea. In other cases they lead to the 
 formation of areas of resistance to the congestion which is 
 general in the pelvis in connection with menstruation. The 
 pressure of the congested vessels affects the nerves in the 
 inflamed and rigid parts, causing pain. In other cases the 
 dys*^enorrhoea may be related chiefly to the effects produced 
 in erus or appendages by the inflammation. 
 
 ,c variety of inflammation which is most often asso- 
 rted with dysmenorrhoea is utero-sacral cellulitis. I shall 
 consider this in relation to pathological anteflexion of the 
 uterus. In all conditions of pelvic inflammation the asso- 
 ciation of neuroses must be borne in mind. 
 
 2. Associated with disease of the Fallopian tubes. — 
 Salpingitis is often the cause of severe dysmenorrhoea. The 
 pains in the worst cases begin two or more days before the 
 
 I \ 
 
DISTURBANCES OF MENSTRUATION. 
 
 123 
 
 period, and are of a spasmodic, agonising character. When 
 the flow begins there is very often considerable rehef, though 
 fre(iiiently the pain lasts through the whole period. The ex- 
 planation of the dysmenorrh(jea, and of th»,' variations which 
 occur, is diffuult. When the walls of the tube are thickened, 
 it is possible that the premenstrual congestion causes the 
 pain, owing to the resistance to the dilatation of the sal- 
 pingeal vessels due to the inflammation. Yet there are 
 cases of well-marked interstitial salpingitis in which there is 
 no increase of pain in relation to menstruation Probably 
 the worst dysmenorrhcea is found with tubes moderately 
 distended with pus. It is believed by some that the intense 
 pain in these cases is caused by expulsive efforts set up in 
 the wall of the tubes under the stimulus of the premenstrual 
 congestion. It is remarkable, however, that some cases of 
 marked pyosalpinx occur in which there is little or no pain 
 at or between the menstrual periods. This is also markedly 
 true of hydrosalpinx and haimatosalpinx. Moreover, the 
 amount of pain is not at all proportionate to the degree of 
 distension of the tubes. Of great importance in these cases 
 is the influence of the pelvic condition in inducing neurotic 
 symptoms. 
 
 3. Associated with disease of the ovaries. — Inflam- 
 mation. — The relation of pelvic pain and of dysmenorrhcea 
 to ovaritis is little understood. It is impossible to eliminate 
 the influence of periovaritis, or of perisalpingitis and sal- 
 pingitis, with which the former condition is often associated. 
 There is no doubt, however, that ovaritis, especially if asso- 
 ciated with periovaritis, may give rise to dysmenorrhcea, of 
 varying degrees of intensity in different cases ; though, 
 sometimes, it may not be marked by any special pain in 
 relation to the menstrual period. Perhaps the most com- 
 mon type is that characterised by the exacerbation of the 
 already existing pain a day or two before the flow, con- 
 tinuing throughout the period. Very often, however, the 
 dysmenorrhcea develops only at the beginning of the flow ; 
 
124 
 
 PUBERTY. 
 
 in some cases it is continued for some days after the 
 period. 
 
 As far as we know, the exacerbation of pain in connection 
 with menstruation in cases of ovaritis can only be explained 
 on physical grounds by the occurrence of congestion in 
 an isolated organ whose expansibility is interfered with by 
 inflammatory changes in or around it. 
 
 For a long time the term "ovarian dysmenorrhoea " has 
 been applied especially to the cases in which the pain is 
 most marked before or just at the beginning of menstruation, 
 
 being supposed that the pain is due to the process of 
 ovulation. I object strongly to the use of this term in such 
 a connection. In the first place, there can be no doubt 
 that the special type of pain here referred to is found most 
 marked in cases where severe tubal inflammation exists, so 
 that no distinction whatever can be drawn between salpingeal 
 and ovarian dysmenorrhoea. In the next place, while it is 
 no doubt true that the escape of an ovum in marked ovaritis 
 or periovaritis is associated with an exacerbation of pain, 
 there is no reason whatever to believe that this process goes 
 on in the majority of the cases of inflamed ovaries in which 
 this special type of dysmenorrhoea is found. Ovulation 
 may sometimes happen to coincide with the beginning of 
 menstruation, but in most cases it does not. There is no 
 necessary coincidence in the occurrence of the phenomena. 
 
 It is necessary to point out with great emphasis that the 
 most marked cases in which reflex neurosis is established or 
 aggravated are those in which the ovaries are the seat of 
 troublesome inflammation. It is, therefore, difficult in any 
 given case to establish a proper relationship between the 
 physical and the neurotic. 
 
 4. Associated with affections of the uteris. — (i) Mal- 
 formations. — In uterus septus and uterus bicornis, if one-half 
 of the uterine cavity is atresic in its lower part, dysmenorrhoea 
 occurs in association with the accumulation of menstrual 
 blood in the part which is shut off". The same symptom is 
 
DISTURBANCES OF MENSTRUATION. 
 
 125 
 
 met with when accumulation occurs in the rudimentary horn 
 in a case of uterus unicornis. Dysmenorrhcea begins in the 
 pelvis on the affected side at puberty. With succeeding 
 periods the pain usually becomes more marked and more 
 prolonged ; it is often like labour pains. 
 
 (2) Stenosis of the cervix. — For a long time one of the 
 most common causes of dysmenorrhcea has been thought to 
 be a narrowing of one part or another of the cervical canal, 
 causing a mechanical obstruction to the escape of the mens- 
 trual flow. In some cases the os internum, in others ihe 
 OS externum, may be the special seat of contraction. Some- 
 times both may be at fault or, indeed, occasionally the whole 
 cervical canal may be narrowed. 
 
 The most erroneous ideas are prevalent in regard to this 
 matter. No definite standards have been set up as regards 
 the size of canal necessary to a painless passage of blood. 
 No account has been taken of the fact that during mens- 
 truation the whole cervical canal becomes somewhat dilated. 
 Measurements made, therefore, between the menstrual 
 periods will not apply to the uterus during their progress. 
 
 It is interesting to note that one observer, Burton, passed 
 the sound into the uterus at the menstrual periods in six 
 cases of dysmenorrhcea, said to be due to stenosis of the 
 cervical canal. In each instance he found that the sound 
 passed very easily, the canal being much more patent then 
 than between the periods. 
 
 It is extremely rare, as John Williams states, to find a 
 case in which, in intermenstrual periods, a sound cannot be 
 passed into the uterine cavity. The percentage of cases of 
 dysmenorrhcea attributable to contraction, however, i;-) very 
 much greater. Moreover, the results of treatment based 
 upon the prevalent hypothesis are very unsatisfactory, i.e. 
 dilatation or division in a very large proportion of cases 
 causes no improvement. In some cases of cure there can 
 be little doubt that the operation has acted, not by its direct 
 influence on the uterus, but by its influence in counteracting 
 
^ 
 
 126 
 
 PUBERTY. 
 
 a neurotic condition from which the patients have been 
 suffering. In other cases, in which the dilatation has caused 
 an improvement, the dysmenorrhcea has been due, not to 
 the attributed stenosis, but to the fact that there is an 
 abnormal tendency to clotting of blood in utero^ to fibrin 
 formation, or to the shedding of abnormally large portions 
 of the uterine mucosa. 
 
 I wish particularly to emphasise the latter point. It is 
 a well-known fact that occasionally a complete cast of the 
 mucosa of the body may be expelled during a menstrual 
 period, and though the cervical canal is normal and under- 
 goes considerable dilatation the most intense dysmenorrha'a 
 is induced. Now, there is, I believe, a proportion of cases 
 in which bits of the mucosa of various sizes are expelled as 
 a regular or irregular habit. And it is to these that the 
 narrowing of the canal is due, interfering with the free 
 escape of the menstrual blood. It does not take a large 
 portion of tissue to block the cervical lumen at the upper 
 or lower end. 
 
 It is extremely likely that in cases of dysmenorrhcea, said 
 to be due to spasmodic contraction of jhe os internum or 
 03 externum, the contraction is induced by the presence of 
 a portion of mucosa within the circle of muscle. This can 
 be easily understood when one remembers how, in passing 
 a sound into the uterus, it may often be held very firmly 
 by a spasm of the musculature at the os internum. I am, 
 therefore, of the opinion that a considerable proportion of 
 cases of dysmenorrhcea should be classed as " membranous 
 dysmenorrhcea," using this adjective to apply to portions of 
 mucosa, great or small. 
 
 While in Edinburgh I had under my observation for over 
 a year a most interesting case of severe dysmenorrhcea, in 
 which in successive periods portions of mucosa, varying in 
 size from a complete cast of the cavity of the body to a 
 piece not larger than a ten-cent piece, were passed. The 
 menstrual discharge was carefully collected and examined 
 
DISTURBANCES OF MENSTRUATION. 
 
 127 
 
 at each period. She had suffered for over two years, the 
 pain varying in intensity from time to time. At some of 
 the periods, had not the discharge been most carefully 
 examined, the true nature of the case would not have been 
 made out. 
 
 In another set of cases, dysmenorrhcea is attributed to a 
 narrowed cervical canal, when it is really due to an inflam- 
 matory condition in or near the uterus. Also the element 
 of neurosis is undoubtedly overlooked in many instances, 
 as an important factor in producing the dysmenorrhcea. 
 
 There is, therefore, but a very small residuum of case 
 in which it can be held that dysmenorrhcea is directly and 
 solely due to a stenosis of the cervix. These are probably 
 instances of congenitally elongated, conical cervix of abnor- 
 mally small calibre, or of rigidity of the cervix induced by 
 inflammatory changes, conditions interfering with the dila- 
 tation which occurs in the cervical canal normally during 
 menstruation. 
 
 (3) Inflammation in the uterus. — Dysmenorrhcea is fre- 
 quently found in association with endometritis. Under 
 this heading must be included all the cases to which I have 
 referred, under the name of " membranous dysmenorrhcea." 
 When a complete layer of the mucosa is shed, it is due tO 
 the widespread interstitial inflammation rendering the super- 
 ficial portion of the mucosa impermeable to blood. The 
 latter escaping into the substance of the mucosa dissects a 
 portion off. Tii° loosened portion is expelled by the uterus, 
 and as it is forcec' down it either breaks across or pulls after 
 it part or the whole of the remaining superficial layer of the 
 mucosa. The passage of the membranous masses through 
 the cervix causes reflex spasms of the musculature, especially 
 at the OS internum ; this further interfering with the down- 
 ward progress of the uterine contents. The uterine wall is 
 thus further stimulated to contraction, and so great pain is 
 I)roduced. 
 
 As I have already stated, apart from the shedding of 
 
 M I 
 
 11 
 
 I 
 
V. 
 
 128 
 
 PUBERTY. 
 
 I 
 
 complete or very large casts of the mucosa, there is probably 
 a considerable number of cases in which small portions of 
 different sizes are expelled, the severity of the dysmenorrhoea 
 varying greatly. 
 
 There is one uncommon form of endometritis, the villous 
 or papillary, in which projections of granulation tissue ex- 
 tend into the cavity. These may cause dysmenorrhoea, 
 either by becoming swollen with the congestion of mens- 
 truation and thus stimulating the uterus to contraction, 
 or by being broken off and expelled, causing pain in the 
 manner just described. 
 
 No doubt many cases of dysmenorrhoea attributed to 
 endometritis are really due to chronic metritis. In this 
 condition, the indurated state of the uterus, owing to the 
 increased amount of fibrous tissue in its wall, opposes 
 the softening and relaxation of menstruation, and the in- 
 creased congestion leads to greater pressure on the nerve 
 fibres in the wall. 
 
 Great variations are found as regards the occurrence of 
 dysmenorrhoea in metritis. In some cases it is not present 
 at all. These variations are probably dependent upon the 
 extent and situation of the inflammation, the size of the 
 lumen, and the amount of fixation of the uterus by outside 
 inflammation. The latter point is of considerable import 
 ance. Given a uterus in a condition of metritis, firmly 
 fixed by peritonitic adhesions or cellulitic deposits, and 
 there is the most favourable combination for the occurrence 
 of dysmenorrhoea. The condition is exactly analogous to 
 chordee in the male, in which intense pain is produced 
 owing to the opposition to congestion of the penis, caused 
 by the inflammation. 
 
 This combination is most frequently found in women in 
 the diseased state known as pathological anteflexion, associ- 
 ated with utero-sacral cellulitis or posterior perimetritis. 
 Here the dysmenorrhoea is due, not to <^he flexion in the 
 uterus, but to the inflammation in and behind the organ 
 
DISTURBANCES OF MENSTRUATION. 
 
 tzg 
 
 opposing tlie congestion of the menstrual period, thereby 
 leading to marked pressure on the nerves. 
 
 Finally, in all cases of metritis, the importance of an 
 accompanying neurosis as a factor in causing pelvic pains 
 must be kept in mind. 
 
 (4) Displacements of the uterus. — It is probable that, in 
 the great majority of cases, displacements of the uterus 
 per se have nothing to do with dysmenorrh(jea. If the 
 condition of the escaping of menstrual blood be normal, 
 there is no reason why the existence of an abnormal degree 
 of version or flexion of the uterus should prevent the down- 
 ward progress of the blood. 
 
 Schultze and Scanzoni demonstrated in a number of 
 cases of intense dysmenorrhfjua associated with anteflexion, 
 that there was no retention of blood in the cavity whatever. 
 The passage of the sound was in no instance followed by 
 any relief or by any escape of blood. 
 
 Neither is there any ground for believing that a flexion 
 interferes with the congestion of the uterus at menstruation. 
 The blood vessels in the uterine wall run towards the 
 mucosa mainly at right angles or oblicjuely from the vessels 
 outside the wall, derived from the ovarian and uterine 
 arteries, as Williams has shown. No flexion alone, there- 
 fore, can affect the circulation in the wall. 
 
 The explanation of dysmenorrhcea in cases of flexion is as 
 follows :— In some cases the causes are metritis and fixation 
 of the uterus, as held by Schultze, e.g. in the condition 
 already referred to, where marked anteflexion is associated 
 with inflammation in the uterus and behind it. The same 
 conditions may be found in a marked retroflexion, where the 
 fundus uteri is deeply placed in the pouch of Douglas. 
 
 It is a common clinical experience that many of these cases 
 are improved by treatment of the inflammatory conditions 
 present. Exact observations on this point have been made 
 by Schultze, who points out that the dysmenorrho^a may 
 be cured as the inflammatory products are absorbed, even 
 9 
 
i 
 
 1 
 
 ' 
 
 130 
 
 PUBERTY. 
 
 though the flexion of the uterus may remain exactly the 
 same. 
 
 In another set of cases, where a very acute flexion exists, 
 and where there is a tendency to fibrin formation or blood- 
 clotting in utero, or to the exfoliation of portions of the 
 mucosa owing to endometritis, it is not diflicult to under- 
 stand why there may be obstruction to the escape of the 
 uterine contents, and cons'^quently dysmenorrhcea. In a 
 considerable number of cases also, the pain is referable to 
 a neurotic condition. 
 
 That many cases of marked displacement exist in which 
 there is no dysmenorrhcea, is a well-established clinical fact. 
 Such examples indicate clearly that other factors are neces- 
 • sary to the production of the dysmenorrhcea. 
 
 In inversion of the uterus there may be great pain at the 
 menstrual periods. In the slowly produced variety it is 
 easy to understand why this should be so. The inverting 
 portion becoming congested at the menstrual period stimu- 
 lates the rest of the organ to contractions, which tend to 
 increase the extent of the inversion. In chronic conditions 
 there are usually marked inflammatory changes in the uterine 
 wall, which tend also to induce the dysmenorrhcea. 
 
 (5) Fibromyoma of the uterus. — Dysmenorrhcea is a 
 common symptom in fibromyoma of the u^'^rus, and it 
 occurs under different conditions. 
 
 In cases of submucous fibroids, which are tending to 
 project into the uterine cavity, the pains are usually severe 
 and labour-like. The polypus swells with the menstrual 
 congestion, thus acting as a stimulus to uterine contrac- 
 tions. In large, pediculated, subperitoneal fibroids, there 
 may be dysmenorrhcea of a stretching or dragging nature, 
 due, according to Gusserow, to the distension of the tumour 
 with blood. Great pain may also be produced when such 
 tumours have fallen within the true pelvis, the congestion 
 due to menstruation causing pain by increasing the weight 
 of the tumour, by causing pressure symptoms on surround- 
 
DISTURBANCES OF MENSTRUATION. 
 
 131 
 
 ing structures, and possibly by stimulating tbe uterus 
 to contraction. Similarly, dysmenorrhcra may be caused 
 when large interstitial fibroids cause the uterus to increase 
 so that it fills the pelvis. 
 
 II. — Dysmenorrha'.a associated with slight or ivithout any 
 recognisable pelvic lesions. 
 
 A large number of cases of dysmenorrhoea occur in 
 women without distinct pelvic lesions sufficient to explain 
 them. In these the predominant factor is disturbed inner- 
 vation in one or other of its various manifestations. This 
 subject is further considered in the chapter on " The Ner- 
 vous System in Relation to Pelvic Diseases." 
 
 Menstruation in relation to mental irresponsibility in 
 woman. — It is held by many, that in medico-legal inves- 
 tigations the mental condition of woman during her 
 menstruation should be taken into account, and that 
 inquiry should be made, in the case of a committal of a 
 crime, whether it occurred immediately before, during, or 
 after a period. 
 
 Krabt Ebing states that the examination of the mental 
 condition is especially important, if any peculiarity in 
 behaviour or nervous disturbance has been noted in con- 
 nection with menstruation. He insists that if that process 
 has had a marked influence upon the ideation of the 
 woman, that fact should be regarded as an extenuating 
 factor in deciding the punishment, even where there is no 
 clear proof of menstrual insanity. If a crime has been 
 committed during menstruation, by one who had been 
 accustomed to be mentally disturbed at this time, and if 
 the act denote impulsiveness, the accused should be 
 regarded as irresponsible, in the opinion of this authority. 
 But he adds that persons pardoned on such a ground 
 should be kept under surveillance for a time, in order that 
 their habits might be studied in connection with menstruation. 
 
I I 
 
 CHAPTER V. 
 
 THE NERVOUS SYSTEM IN RELATION TO 
 PELVIC DISEASES. 
 
 
 Notwithstanding the great increase in neuroses among 
 women during the present generation, it must be confessed 
 that in the gynecological world scant attention has been 
 paid to them. 
 
 Owing to the marked surgical trend in gynecological 
 practice during the last twenty-five years, a narrow and 
 debased specialism has been evolved which has resulted 
 in the establishment of a school whose motto is Le bassin 
 c'est lafettwie, and whose remedial measures are limited to 
 different forms of mechanical procedure — from passing a 
 sound to extirpating the appendages. 
 
 Too strong a protest cannot be urged against the cen- 
 tralisation of attention on the local pelvic condition, without 
 regard to wider physical and psychical relationships. Pascal 
 has a chapter, in his famous book, entitled " Man's Dis- 
 proportion." The term might justly be applied to the 
 mechanical school of gynecologists, who have done so 
 much harm by their failure to give to the various symptoms 
 related to the pelvis, their proper proportional values. 
 
 The accusation of the broad-minded physician, that the 
 gynecologist works in ignorance of the neuropathies and 
 organic diatheses in that region of the body where they are 
 of chief importance, is a well-merited one ; and the majority 
 of specialists will, be they honest, acknowledge its force, 
 and humbly confess, " Peccavi." I do not say that there is 
 
 H 
 
SUBJECTIVE PHENOMENA. 
 
 133 
 
 no truth in the countercharge, brought by the specialist 
 against the general physician, of a narrow sciolism which 
 is incapable of estimating the significance of local pelvic 
 phenomena; yet I firmly believe that the specialty of 
 gynecology will never reach a position of highest repute 
 until it is established " broad-based " upon the philosophic 
 attitude, the wide culture, and the extensive knowledge 
 which formed the sutnmum bonum of attainment among 
 the great masters of medicine in past generations. 
 
 These defects in us lead to error both in diagnosis and in 
 treatment. In considering a case of pelvic pain, we should 
 bear in mind the following points : — 
 
 1. The pain may be directly due to distinct pelvic lesions, 
 sufficient in themselves to produce this symptom. 
 
 2. Pain may exist with minor degrees of pelvic trouble, 
 insufficient in themselves to cause more than a small 
 amount of suffering. 
 
 3. Pain may be a pelvic symptom in association with 
 some condition which in itself cannot directly produce this 
 symptom. 
 
 4. It may be a prominent symptom in cases in which no 
 local changes of any kind can be made out. 
 
 It is, therefore, very evident that other than local factors 
 must be taken into account as explanatory of the subjective 
 phenomena which we are considering. Of chief importance 
 among these is the neuropathic state — neurosis, in the 
 widest meaning of the word. This condition is related to 
 the pelvis in various ways. 
 
 In one set of cases, a local lesion, capable or not in itself 
 of causing pain, may be the primary cause of developniCnt 
 of a neurotic condition manifested by diverse phenomena. 
 The more marked these become, the more is the pelvic 
 pain intensified — a reactionary exhibition of the neurosis, 
 as it were, on the seat of the primary affection. In 
 another class of cases, there may be a slight pelvic lesion 
 causing very little discomfort. A neurotic condition may 
 
1 34 iV-^ A" ^'0 US S YS TEM AND PEL VIC DISEASES. 
 
 be developed from causes foreign to the pelvis, and this 
 may manifest itself in intense pain, referred by the patient 
 to the pelvic lesion. In another set, the symptom of pelvic 
 pain is developed as one of the phenomena of a widespread 
 neuropathic state, there being no local lesion of any kind. 
 
 There is another interesting class in which the local 
 symptom is practically the only neurotic feature in the 
 patient. In some of these cases the condition is somewhat 
 like that in which the possession of a " fixed idea " is char- 
 acteristic. In others, it is of the nature of a "secondary 
 reflex action," induced by a former continuity of habit, when 
 there was an actual painful local lesion which has since 
 been cured. The patient's nervous system has so registered 
 the former habit that it is reproduced apart from all contact 
 of the higher inhibitory centres. 
 
 This power of impressing the nervous system is a well- 
 recognised biological truth. It is well exemplified in the 
 case of the gouty man whose foot has been amputated, and 
 who continues to have attacks of pain in the same toes as 
 of old. Of similar nature is the remarkable instance of the 
 mare which, on being crossed with a stallion, bore a foal 
 striped like a quagga — as a result of the influence of a 
 previous conception following crossing with a male quagga. 
 
 Herbert Spencer quotes the case of a dachshund bitch 
 which bore pups to a sheep-dog ; in two succeeding years 
 she bore them to a pure dachshund, but the offspring took 
 after the sheep-dog as much as after the real fathers. In 
 another case a pointer bitch bore puppies to a setter, and 
 never afterwards was able to breed pure pointers though 
 crossed with a pointer. Lord Polwarth, a great authority 
 on breeding, states that if a ewe Leicester sheep breeds to 
 a Shropshire ram, she is never safe to breed pure Leicesters 
 from afterwards, as dun or coloured legs are apt to come even 
 when the sire is a pure Leicester. Breeders of Bedlington 
 terriers have taken advantage of this curious influence of 
 telegony, as it is called, to breed dogs with strong jaws. 
 
 i \ 
 
NEURASTHENIA. 
 
 US 
 
 They first cross the Bedlington terrier bitch with a bull-dog, 
 and destroy the litter which results. Afterwards, on cross- 
 ing the same bitch with a Bedlington dog, litters are 
 produced in which there is a good deal of the bull-dog 
 jaw and spirit. 
 
 As regards man, Balfour pointed out in 1851 that in 
 Surinam, if a negress had a child or children to a white 
 man and later to a negro, the latter progeny had a lighter 
 colour than the black parents. It has also been observed 
 that children of white people had often shown traces of the 
 negro character when the woman had previously had a 
 child by a negro. 
 
 By the neuropathic or neurotic condition I do not mean 
 hysteria. This is only one of a variety of neuroses. Yet 
 too often are women turned away from the mechanical 
 gynecologists, whose pelvic manipulations have failed to 
 cure them, as wretched hysterics. 
 
 One of the greatest services rendered to medicine has 
 been the establishment of the distinction between neuras- 
 thenia and hysteria. This we owe to the work of men like 
 Weir Mitchell and Clifford Allbutt, who have taught us 
 that these terms are not synonymous, though often certain 
 phenomena are common to both conditions. 
 
 Neurasthenia, also known by the terms "nervous ex- 
 haustion," " nervosism," " spinal irritation," is a condition 
 not yet clearly understood, though its varied manifestations 
 are pretty thoroughly tabulated. The condition gradually 
 develops in most cases, and is most common in the upper 
 ranks of life. 
 
 That neuroses should be so common in women is not to 
 be v/ondeied at. Though Michelet's dogma is not true, 
 that "woman's life is a history of disease," it must be 
 admitted that it is one of physiological unrest, except in 
 youth and old age. When we remember the great dis- 
 turbances which mark the advent and departure of the 
 reproductive era of her life, the profound changes taking 
 
136 NERVOUS SYSTEM AND PELVIC DISEASES. 
 
 \ 
 place during ovulation, menstruation, pregnancy, labour, 
 
 and lactation ; the subtle and complex activities of her 
 physical life in its various diastaltic functions, it is not 
 remarkable that neuroses should manifest themselves par- 
 ticularly in relation to her reproductive mechanism. That 
 they are increasing pari passu with the advance in our 
 higher civilisation cannot be denied, — among the poor, the 
 inducing factors being over-work, over-worry, ill-regulated 
 and poor nutrition ; among the well-to-do, educational 
 strain, over-indulgence, the stress of modern life, emotional 
 excitement. 
 
 A condition is developed in which the whole nervous 
 system is below par, due, it may be, to over-strain, imper- 
 fect nutrition, faulty development ; the manifestations being 
 irregular or excessive activity, abnormal sensitiveness, men- 
 tal unrest and anxiety. According to Arndt, though there 
 is a deficiency of nerve power, there is an increase in 
 energising, due to a weakness in inhibitory power and to 
 the too ready icsponse of the nervous system to stimuli. 
 In the worst stages of the condition the increased excit- 
 ability has changed to a state in which there is a blunting 
 of the nerve sensibility. 
 
 Hyperaesthesia and motor weakness, then, are the chief 
 features of neurasthenia. Abnormal sensations and pains 
 may be felt in different parts of the body. Cramps and 
 twitchings may develop. The pupils may be unequal in 
 size ; the tendon reflexes are often exaggerated ; there is 
 often a feeling of languor and of unfitness for work. The 
 appetite fails ; pains in the stomach and bowels may 
 develop, along with indigestion, constipation, etc. Emacia- 
 tion is common ; though, in some cases, fat is increased, 
 the patient appearing pale and unhealthy, however. The 
 urine is of low specific gravity, may contain deficient urea, 
 and often abundant phosphates. Sleeplessness often de- 
 velops. The woman may become very anxious and be 
 subject to various fears ; various other abnormal emotional 
 
 \\ 
 
HYSTERIA. 
 
 «37 
 
 '•/ 
 
 and mental symptoms may gradually become established, 
 and in extreme cases some form of insanity may arise. 
 
 Neurasthenia may lead to hysteria, and may have symp- 
 toms which are found in hysteria, but it is important to 
 keep in mind the great difference between the conditions. 
 As AUbutt puts it, neurasthenia is the state in which there 
 is "defect of endurance," hysteria that in which there is 
 " defect of the higher gifts and dominion of mind." " The 
 neurotic woman is sensitive, zealous, managing, self-forget- 
 ful, wearing herself out for others ; the hysteric, whether 
 languid or impulsive, is purposeless, introspective, and 
 selfish." 
 
 Hysteria is a condition in which especially the higher 
 nervous centres are at fault. Charcot calls it a psychic 
 disease. According to Havelock Ellis, the general charac- 
 ter of the mental phenomena in hysteria may be summed 
 up in the word suggestibility. There is an abnormal 
 degree of response to suggestion in the nervous system. 
 There is a partial or complete loss of inhibition in regard 
 to voluntary actions, and also a disturbance of the nervous 
 centres regulating the automatic movements. The weak- 
 ness of inhibition is associated with the tendency to erratic 
 and extravagant reactions to stimuli — the state which has 
 led Fere to give to the hysteric the name " frog of psycho- 
 logy." Then there is the tendency for many or varied 
 nervous phenomena to spread from a small area of excitation. 
 
 The powers of the higher centres may greatly alter in 
 regard to the initiation of movements ; sensory perception 
 may be partially or entirely wanting. 
 
 Bastian sums up the symptoms under the following 
 heads : — 
 
 I. Mental. — Judgment, accuracy, and power of concen- 
 tration are weakened. The emotions are easily excited and 
 badly controlled. There is a morbid desire for the sym- 
 pathy of others ; she craves attention continually, is full of 
 caprices, and makes excessive demands on those about her. 
 
138 NER VOUS SYSTEM AND PEL VIC DISEASES. 
 
 As Wendell Holmes says, " she is a vampire who sucks the 
 blood of the healthy people about her." If she is checked 
 or chided in any way, she takes offence, gets irritated, bursts 
 into tears, or has an attack of pain^ paralysis, or some other 
 manifestation of the hysterical condition. 
 
 There is often a tendency to tell untruths and to practise 
 deceptions. Clouston has pointed out particularly the 
 changes due to the loss of inhibitory influence on the 
 reproductive and sexual instincts. There may be various 
 perversions of sexual emotion, e.g. abnormal yearning for 
 love. Formerly these alterations were exaggerated ; now, 
 possibly, too little attention is paid to them. When these 
 cases become extreme and hysterical insanity is developed, 
 the prominence of sexual and erotic ideas is marked ; there 
 is often mock modesty ; often a tendency to describe her 
 pelvic condition with great detail ; in some cases, they have 
 visions in which coitus plays a prominent part ; sometimes 
 they imagine they give birth to various animals. 
 
 Lombroso has pointed out that criminal acts performed 
 by the hysterical are very often conrer ed with sexuality. 
 
 2. Sensory. — Pains, hypera^sthesia, and anaesthesia are 
 found. Pain is apt to cease suddenly when the attention 
 of the patient is taken from her condition. Common seats 
 of pain are the lower part of the chest, especially on the left 
 side ; the region of the spines of the vertebrae, especially 
 the upper ones ; joints, especially if there has been a slight 
 injury ; the mammas ; the skull ; the epigastric and iliac 
 regions. Pressure over painful areas may cause marked 
 changes, e.g. disturbances of respiration and circulation, 
 great increase in the pain, hysterical convulsions, etc. In 
 some cases, by pressure over the ovaries, marked hystero- 
 epilepsy may be caused. 
 
 Anaesthesia may exist over the whole surface ; more often 
 it is one-sided, especially left. It may be confined to a 
 small area or may be irregularly distributed. The special 
 senses may be disordered, e.g. there may be intolerance of 
 
HYSTERIA. 
 
 139 
 
 light ; loss of vision, smell, taste, hearing, etc. ; numbness, 
 coldness, prickings, etc. 
 
 3. Motor. — There may be various local spasms, general 
 convulsions, paralysis. Globus hystericus is the condition in 
 which the patient feels a lump pass from the epigastrium to 
 the throat, choking her and often causing her to cry. 
 
 Cough is a common symptom when the patient is ob- 
 served ; it is absent when she is alone. Sometimes it is 
 accompanied with ai iudant mucous discharge. I . some 
 cases, inspiration may be jerky and spasmodic, accompanied 
 with a choking sensation ; in other cases, expiration is of 
 the nature of a wheeze, a whistle, a dog-bark, or it may be 
 like laughing or crying. Yawning, hiccough; sneezing may 
 be met with. 
 
 Clonic spasms may be met with in different parts, e.^. 
 neck, back, thigh. Tonic spasm is more frequent. Con- 
 tracture of limbs may thus be caused and may continue for 
 years, lasting during sleep and anesthesia. If this occurs in 
 the abdominal wall, an abdominal tumour may be simulated. 
 
 Convulsions are common and may be ushered by various 
 symptoms, c.i::;. pain, giddiness, choking, shrieking. When 
 the patient falls in one of these attacks, she does not usually 
 hurt herself or fall in the fire. There is often more or less 
 opisthotonos. Consciousness is often retained, but it may 
 be partly or wholly in abeyance. Self-infliction of injury is 
 absent and the tongue is rarely bitten. These attacks may 
 be single or multiple and successive. Paralysis may be 
 found ; paraplegia is common ; hemiplegia less frequent. 
 There may be incapacity for speech, or aphonia ; some- 
 times the tongue or neck cannot be moved. 
 
 4. Circulatory, — Syncope may be developed and may 
 sometimes be very marked, the pulse becoming feeble and 
 the patient prostrated. In some cases irregular and bound- 
 ing cardiac action is present. The aorta may pulsate 
 strongly. here may be abnormal capillary action, e.g. 
 hypen\imia, ischa;mia. 
 
1 40 NER VO US S YSTEM AND PEL VIC DISEASES. 
 
 5. Visceral, — Vomiting is common. Disturbed digestion, 
 flatulence, constipation, diarrhcea may be found. Disten- 
 sion of the bowels may occur, forming phantom tumours. 
 There may be retention of urine, dysuria or frequency of 
 micturition ; sometimes suppression of urine. Pains occur 
 in the region of the kidneys, ovaries, uterus, coccyx, etc. 
 Dysmenorrhoea is common. 
 
 Sequela. — It is important to remember that hysteria may 
 pass into actual mental disease, e.g. mania, melancholy, 
 dementia. 
 
 Reflex neuroses in pelvic disease. — It is to be noted 
 that various forms of pelvic disease may be the starting- 
 point of a variety of symptoms produced reflexly, and 
 affecting mental, sensory, motor, circulatory, and visceral 
 functions. These disorders vary greatly as regard the site, 
 degree, and extent of their manifestation in different cases. 
 Neuralgic pains are, perhaps, most common. In some 
 cases the pelvic lesion may be the starting-point of a long 
 spell of neurasthenia or hysteria, or of other nervous con- 
 ditions, e.g. epilepsy or chorea. 
 
 Relation of pelvic diseases to insanity. — This relationship is 
 not definitely established. Insane women undoubtedly have pelvic 
 diseases just as sane women have, but whether there is any connection 
 between them of the nature of cause and effect, it is impossible to say. 
 It has been proposed by sc .e to remove the appendages in cases where 
 abnormal sexual aberrations are pari, of the insane manifestations, but 
 there is no rational ground for such a procedure. 
 
 Rohe states that 60 per cent, of the women in the Maryland 
 Asylum have pelvic disease or developmental defects, the latter being 
 often found among "degenerates." He thinks that these lesions 
 should be treated just as they would be in sane women. lie gives an 
 account of 34 cases on whom operations were performed, 30 being 
 abdominal sections for the removal of the appendages. In 3 of these a 
 secondary vaginal hysterectomy was done, in 2 repair of a lacerated 
 cervix, in 2 vaginal removal of uterus and appendages 
 
 Of the 30 abdominal sections, 10 were cured physically and mentally, 
 4 were decidedly improved, 13 were unimproved, 3 died. Of the 3 
 secondary vaginal hysterectomies, i was cured and 2 not improved. 
 Of the 2 primary total extirpations, one was cured and the other 
 
rHEATMENT OF PELVIC PAINS. 
 
 141 
 
 improved. The 2 trachelorrhaphies both recovered, mentally and 
 physically. 
 
 The forms of insanity in which recovery took place were : puerperal 
 mania, 4 ; melancholia, 6 ; mania, 3 ; hystero-cpilepsy, I. Total, 14. 
 
 Those in which complete recovery did not follow were : melancholia, 
 2 ; mania, 5 ; puerperal mania, i ; dementia (including 4 epilepsy), 7 
 (3 deaths) ; paranoia, 2; hysterical insanity, 2; adolescent insanity, i. 
 Total, 20. Rohe believes that early operation would increase the 
 proportion of recoveries. 
 
 Treatment of pelvic pains in women. — In the treat- 
 ment of pelvic pain the failure to consider the existence of 
 relationships between local and general conditions, between 
 pelvic suffering due to and commensurate with pelvic lesion 
 and that which is due to neurosis, and the fixation of the 
 attention upon the local state, have resulted in a form of 
 practice very often fraught with disappointment both to 
 physician and patient, not to speak of the evil consequences 
 to which I have above alluded. 
 
 In one of the very latest articles on the treatment of 
 dysmenorrhoea, by one of the recognised leaders among 
 P2nglish gynecologists, not a single word is given to indicate 
 that it is at all necessary to pay attention to neurotic com- 
 plications, whereas I make bold to say that, taking all sorts 
 and varieties of dysmenorrhoea into consideration, it is the 
 factor which is most common to all, which requires most 
 careful attention and in many cases sole attention. 
 
 The narrow and mechanically-minded specialist, on com- 
 ing into contact with a case of dysmenorrhoea, at once 
 proceeds to establish a locus standi in the pelvis. He 
 argues : " The patient complains of pain in the pelvis ; it 
 must be in the pelvis ; its cause is in the pelvis ; its treat- 
 ment must be by measures directed to the pelvis." He 
 then has a choice of procedures. Probably he thinks first 
 of uterine flexion, and a stem pessary may be brought into 
 requisition ; or he may diagnose a stenosis of the os, and pro- 
 ceed to a dilatation or to a cutting operation ; or he may deem 
 the ovaries at fault, and decide heroically on their removal. 
 
I 
 
 142 NERVOUS SYSTEM AND PELVIC DISEASES. 
 
 It may be that he will carry out these different opera- 
 tions seriatim, in the chance that he will at last hit on the 
 successful one. Sometimes he cures the patient — some- 
 times he does not. When he is successful, he attributes 
 the good result directly to his operation, forgetting that very 
 often benefit is obtained either through its indirect effect on 
 her nervous system, or by the influence of the rest, change 
 of scene, diet, etc., with which the operative treatment is 
 accompanied. 
 
 The history of gynecology is one of a succession of 
 periods of concentrated attention to one ^fter another of 
 the pelvic contents. Before the days of the bimanual 
 examination, when every gynecologist wielded the tubular 
 speculum, the supposed great source of pelvic trouble was 
 the so-called "ulceration of the cervix," and there are well- 
 founded traditions of fabulous fortunes made by those who 
 devoted their lives to the touching of these diseased spots 
 with various applications. 
 
 Then, with the discc'^ery of the uterus, came the period 
 of displacements and contractures, when nature's mistakes 
 were remedied by pessaries and dilators and scissors. 
 Then, the era of the ovaries, and finally, that of the tubes. 
 Now, at the end of the chapter, what can the fin de siecle 
 gynecologist do but practise upon the whole gamut of his 
 predecessors, giving special attention to one or another 
 according to his particular bent or predilection. And so we 
 find the country getting filled with women nursing a 
 grievance against their wombs, their ovaries, or their tubes, 
 and in many instances possessing d'agrams of their pelvic 
 topography furnished by their zealous gynecological 
 physician, in order, I suppose, that they may, in their 
 leisure hours, exercise their already over-stimulated 
 introspective faculty with more scientific exactness. 
 
 Who that has read Clifford Allbutt's lectures on 
 visceral neuroses, has not smiled at his account of the 
 woman "entangled in the web of the gynecologist, who 
 
 \ 
 
 :; 
 
 \ \ 
 
 >K 
 
TREATMENT OF PELVIC PAINS. 
 
 M3 
 
 jds her uterus, like her nose, a little on one side ; or 
 again, like that organ, running a little ; or as flabby as her 
 biceps, so that the unhappy viscus is impaled upon a 
 stem, or perched upon a prop, or is painted with carbolic 
 acid every week in the year except during the long vacation, 
 when the gynecologist is grouse-shooting, or salmon-catch- 
 ing, or leading the fashion in the Upper Engadine." 
 
 Should the gynecologist's moral sense become somewhat 
 blunted, it is not difficult to understand why he may fall 
 into the reprehensible habit of trading on the fears Which 
 naturally fill the minds of women when their reproductive 
 apparatus is out of order, and of elevating into an un- 
 necessary importance conditions which are but trifling. 
 
 Let me not be misunderstood. I am not denouncing 
 local and operative interference, only irrational and 
 injudicious interference. We are all subject to this tempta- 
 tion. We all like short cuts to success. We are all prone 
 to try, sometimes, like Allbutt's bete noir, "to stem the 
 tides of general and diathetic maladies with little Partington- 
 mops of cotton-wool on the ends of little sticks." It is 
 much less troublesome to make a few cuts and to put in a 
 few stitches, than to patiently analyse a subtle and puzzling 
 case, and to exert our whole energy in overcoming an 
 obstreperous or aberrant nervous system. 
 
 Yet it is this latter practice that must be our constant 
 study throughout gynecological work ; our chief study in 
 many cases where pelvic pain and discomfort are prominent 
 symptoms. 
 
 Throughout the orthodox medical fraternities of the most 
 advanced modern civilised countries, there has been a wide- 
 spread neglect of all remedial measures not of a tangible and 
 physical kind. This attitude has no doubt been developed 
 in antithesis to the ridiculous pretensions of the mystics of 
 the dark ages in Europe who were the representatives of 
 Eastern occultism. 
 
 We are taught to denounce with academic scorn, and 
 
144 NERVOUS SYSTEM AND PELVIC DISEASES. 
 
 rightly in most cases, faith-healers, Christian scientists, 
 hypnotists, religious miracle-workers, et hoc genus omne. 
 Yet, if a man will but take the trouble to study this interest- 
 ing congerie of empirics, with an unbiassed and absorbent 
 mind, he will discover that amid their extravagant claims 
 and sententious philosophies, they have all been nursed 
 upon one common germ idea, namely, that the transcendent 
 power in the human organism is that of mind, and that 
 the effects of diseased conditions, especially of those due 
 to neuropathic changes, may be enormously modified by 
 influences brought to bear upon the higher centres. 
 
 If one investigates, for example, miracle-working in sacred 
 shrines, one will easily be convinced that striking cures are 
 there wrought, often in cases which have baffled the best 
 medical skill. The great mass of these cases are examples 
 of neurosis, and they are chiefly manifested in women. 
 That the marvellous transformations which are brought 
 about are due to the special interference of Deity, is a 
 pretentious assumption. One can see as remarkable cures 
 effected through the agency of hypnotism. 
 
 With these various methods of empirical procedure, the 
 medical world can have nothing to do, save, perhaps, in the 
 case of hypnotism. It is our duty, however, not to rail 
 against them in aimless talk, but to sift their claims 
 thoroughly, and to demonstrate with scientific surety 
 wherein lie their errors. It is only in this way that the 
 race of pretenders and charlatans can be eliminated from 
 the earth. 
 
 Let us not, moreover, fail to recognise that all these 
 healing methods have emphasised the fact that the supreme 
 factor in altering neuropathic conditions is the power of 
 conviction and auto-suggestion, acting on the dominant 
 cortical control centres, and through them on the whole 
 nervous mechanism of the bod}^ 
 
 Realising this, it is our duty, in the treatment of pelvic 
 pains in women, to impress strongly upon the mind of the 
 
TREATMENT OF PELVIC PAINS. 
 
 145 
 
 patient the necessity of taking her thoughts from pelvic 
 conditions, to teach her ever to practise self-control, 
 encouraging her sympathetically, removing from her 
 anxiety and fear as to the gravity of her state, and insisting 
 upon the importance of counteracting every development 
 of neurosis that may become manifest in her. 
 
 General measures, e.g. change of scene and occupation, 
 freedom from over-work and worry, improved nutrition, etc., 
 are of the greatest value in many instances. In cases where 
 hysteria or neurasthenia may be marked, the Weir Mitchell 
 treatment should be carried out. This consists in isolation 
 of the patient under the care of skilful nurses for several 
 weeks ; regular massage of trunk and limbs ; improvement 
 of nutrition by highly nourishing and easily digestible food, 
 e.g. milk, eggs, beef-tea, the chief factor being milk ; and, 
 in some cases, faradic electricity applied to the muscles. 
 
 Operative treatment is necessary m many cases, where 
 there is distinct remediable pelvic lesion. But it must be 
 insisted upon that these shall not be placed in the forefront 
 of the therapeutic measures at our disposal, nor shall be 
 undertaken until the entire state of the patient has been 
 investigated, and every effort made to improve her condition 
 on the lines which I have laid down. 
 
 Moreover, it must be remembered that, when local 
 treatment of a pelvic lesion is necessary, the cure will be 
 hastened and more firmly established by careful attention 
 to the improvement of the neuropathic complications with 
 which it is so often associated. 
 
 The rash and wholesale manner in which, in particular, 
 removal of the appendages for the cure of pelvic pain has 
 been carried out, cannot be too strongly condemned. The 
 uselessness of this procedure in a large number of cases 
 has been clearly shown by Playfair in his article in the 
 Obstetrical Transactw?ts, London (vol. xxxiii.). 
 
 i! 
 
 i\ 
 
 10 
 
^ 
 
 CHAPTER VI. 
 
 THE GENITAL TRACT IN RELATION TO 
 MICRO-ORGANISMS. 
 
 In recent years an immense amount of work has been done 
 in investigating the life-history of germs in the genital 
 tract, and the part that micro-organisms play in pelvic 
 disease whether they enter through the vagina or by some 
 other route. 
 
 The Bacteriology of the Genital Tract in Various 
 
 Normal Conditions. 
 
 In the new-bom child, in almost all cases no germs are 
 found in the vagina. Very soon, however, they enter, 
 favoured by baths, washing, the application of oils, etc. 
 Stroganoff states that a bfeech delivery of a female child 
 favours their premature entry. Within the first two weeks 
 gelatin-liquefying germs are rarely found. 
 
 In girls and women various bacilli and cocci may be 
 found in the vagina, as well as sarcina, yeast fungus, etc. 
 One of these germs is known as Doderlein's vaginal bacillus. 
 These germs flourish best when the vaginal secretion is 
 alkaline ; in acid conditions they are killed or weakened in 
 vitality. As a rule, in normal conditions, no germs are 
 found in the uterus or tubes. Menge has carried out an 
 interesting series of experiments regarding the bactericidal 
 properties of the vaginal secretions in fifty non-pregnant 
 women. He introduced into the vagina a number 
 
THE BACTERIOLOGY IN VARIOUS CONDITIONS. 147 
 
 of pathogenic organisms, namely, Bacillus pyocyaneus, 
 Staphylococcus pyogenes, Streptococcus. In all cases he 
 found that in a short time they had all disappeared, 
 whether the vaginal reaction was acid or alkaline. 
 
 He believes that the following are the factors concerned 
 in the germicidal action, arranged in order of importance : — 
 (i) The antagonism between the normal vaginal bacilli and 
 those which were introduced ; (2) the products of the 
 vaginal bacilli ; (3) the acidity of the secretion ; (4) the 
 secretion of the vaginal wall ; (5) leucocytosis ; (6) the 
 absence of free oxygen in the vagina. 
 
 He found these properties in the new-born child where 
 no vaginal bacilli exist. He also found that if two similar 
 specimens of acid vaginal secretion be taken, and one be 
 sterilised by heat, this specimen loses its germicidal power. 
 If to the other specimen an alkali be added, the germicidal 
 power is diminished, but not destroyed ; if this sample be 
 sterilised by heat, it is lost entirely and then becomes a 
 good nutritive nidus. 
 
 It is also believed that the cervical secretion though 
 alkaline is very germicidal to pathogenic organisms. It 
 is, therefore, important to note that the vaginal secretion 
 may vary greatly in its effects on microbes lying in it. 
 While it may soon destroy them in many cases, in others 
 it may only weaken them and destroy their virulence, as 
 Winter and others have shown. This virulence may be 
 regained if the nature of the secretion be altered, e.g. by 
 the action of gonorrhoeal infection, the presence of organic 
 debris, etc. 
 
 As regards the influence of menstruation. — Jacob and 
 others state that the vaginal bacilli are increased during 
 the period owing to the diminution in the acidity of the 
 normal vaginal contents, as a result of the entrance of 
 the blood. Stroganoff examinei^ the cervix during the 
 menstrual flow, and found that in many cases it contained 
 germs, though none that would liquefy gelatin. 
 
 n 
 
p 
 
 148 THE GENITAL TRACT AND MICRO-ORGANISMS. 
 
 In pregnancy, the vaginal secretion is believed to be 
 very germicidal to pathogenic organisms. Stroganoh" found 
 plenty of ordinary vaginal bacilli, but rarely those that 
 would licjuefy gelatin. Kronig performed a number 
 of experiments on pregnant women, introducing many 
 organisms into the vagina. He found that streptococcus 
 was killed before the staphylococcus, and showed that 
 douching of the vagina with antiseptic solutions reduced 
 or destroyed its germicidal power, and that the use of 
 plain water slighUy diminished it. He thinks, therefore, 
 that prophylactic syringing before confinement can do no 
 good, and may be a source of harm. 
 
 Stroganoff has found germs in the vaginal mucus, but 
 none of the gelatin-liquefying kind. 
 
 In the puerperium, the use of antiseptic solutions in the 
 vagina after labour is being discarded by many authorities, 
 save where digital examination has been carried out, labour 
 has been abnormal, or operations have been performed ; 
 and in cases where the patient may be depressed in health 
 from various causes, e.g. nephritis, heart disease, syphilis, 
 anaemia, diabetes, etc. 
 
 In abortions, the vaginal reaction varies according to the 
 amount of blood and debris found in the vagina. The 
 germs also vary greatly in number and nature from time 
 to time; the pathogenic organisms are more apt to be 
 found in the vagina and cervix in connection with abor 
 tions than in any other conditions, probably mostly due to 
 digital examinations and manipulations. 
 
 In old women Stroganoff finds various microbes in the 
 vagina, mostly rod-shaped, smaller on the whole than in 
 sexual life. The vaginal reaction is faintly acid ; in the 
 neighbourhood of the cervix it is neutral or alkaline. In 
 the cervix living germs were found in about 50 per cent, 
 of cases. Very seldom are any detected which liquefy 
 gelatin. 
 
 Micro organisms in the female urethra. — Gawronsky 
 
MICRO-ORGANISMS AND PELVIC DISEASES. 149 
 
 made cultivations from the secretions in the urethra in 
 sixty-two cases. In fifteen of these, bacteria were found ; in 
 three the Streptococcus pyogenes, in eight the Staphylococcus 
 pyogenes aureus, in one the Staphylococcus pyogenes albus, 
 in two the Bacterium colt commune. Amongst the negative 
 cases were ten where the women had peri or parametritis ; 
 six, prolapse ; three, pregnancy. 
 
 Relation of Micro-Organisms to Pelvic Diseases. 
 
 At the present time the tendency is to attribute the great 
 majority of pelvic inflammations to the action of micro- 
 organisms. The inflammatory processes are simply, to state 
 the modern view, the series of phenomena caused by 
 nature's resistance to the noxious influence of the infecting 
 organisms. These processes are, therefore, not evil in 
 themselves, but are beneficial and purposeful. The most 
 important germs which act as infecting agents are as 
 follows : — 
 
 Streptococcus pyogenes {n\o%i frequent source of trouble). 
 Staphylococcus pyogenes aureus. 
 Bacterium colt commune. 
 Gonococcus. 
 
 The following are less often a source of trouble : — 
 
 Staphylococcus pyogenes albus. 
 Staphylococcus pyogenes citreus. 
 Staphylococcus epidermidis albus. 
 Bacillus pyocyaneus. 
 Diplococcus pneumonicE. 
 Ttibercle bacillus. 
 
 These germs may gain entrance by the vagina, rectum, 
 bladder, intestine, or may be carried from some distant 
 part by the circulation. 
 
 The conditions which favour their entrance are a favour- 
 able soil, e.g. a raw surface, a tissue of impaired vitality, 
 a general condition of poor health in which the resistance 
 

 I 
 
 150 T/^E GENITAL TRACT AND MICRO-ORGANISMS. 
 
 of the tissues is below par, dying organic matter, — e.g. the 
 remains of placenta or membranes in iitero or blood clot 
 that has been formed for a little time. 
 
 In some cases the micro-organism is capable of attacking 
 the tissues when they are in a state of perfect health, e.g. 
 gonococcus. 
 
 The most common source of entrance for the various 
 germs is undoubtedly the vagina. They may spread up 
 into the uterus and along the tubes, reaching the peri- 
 toneum, either setting up infective processes along this whole 
 extent, or by growing in some suitable discharge or debris 
 which lines the passage ; or they may enter a raw, injured, 
 or diseased surfiice, and spread to cellular tissue, peritoneum, 
 tubes, or ovaries by means of veins and lymphatics. 
 
 The part played by germs which find entrance by way 
 of the rectum and intestine is not yet well known. In all 
 probability it is greater than has been understood. The 
 frequency of retro-uterine inflammation in women, especially 
 in the unmarried, is in my opinion not related so much to 
 infection from the uterus as from the rectum. Experiments 
 (I shall describe some of these on p. 300) clearly show 
 how quickly the Bacterium coli commune can penetrate the 
 bowel wall and adjacent tissues, if they be at all impaired in 
 vitality. 
 
 In the rectum, the overstretching of the wall from consti- 
 pation, so common in women, the continual soaking of the 
 wall in this state with toxic matters being absorbed from 
 the gut, the occasional occurrence of cracks and ulcers, are 
 all factors which favour the passage of the bacterium coli 
 into the utero-sacral ligaments, the surrounding cellular 
 tissue and peritoneum, and even the uterus. Higher up in 
 the intestinal tract, overloading of the bowel, pressure on it, 
 ulceration, may also bring about the same movements in the 
 bacteria. 
 
 The bladder is probably an uncommon source of entrance. 
 Where it has become infected on its mucous surface, and 
 
 .'';. 
 
MICROORGANISMS AND PELVIC DISEASES. 151 
 
 where the vitality of the wall is impaired, e.^. by ulceration, 
 pressure, or tumour growth, germs may pass from it to 
 surrounding tissues. 
 
 The exact relationship between germ action and various 
 other factors, which have long been regarded as causal in 
 the produc on of pelvic inflammations, has not yet been 
 definitely established. I shall consider these in connection 
 with the various diseases themselves. 
 
 Thus, menstruation has always been considered important 
 in relation to the causation of inflammation, especially in 
 the uterus, a chill or extra exertion being considered as 
 playing a leading role. Now we are inclined to think that 
 menstruation as a factor acts probably more by altering the 
 nature of the vaginal secretion, rendering it more suitable 
 for the growth of the pathogenic germs which might be 
 lying in it, and thus making it more easy for them to 
 extend upwards into the uterus. No doubt other influ- 
 ences, e.g. chill, fatigue, etc., might also favour their 
 activity, by interfering with the normal resisting powers 
 of the tissues. 
 
 Excessive coitus, especially at menstruation, is said to 
 lead to inflammation, e.g.^ in the uterus. There is no proof 
 that the mere physical excitement can bring about this 
 change. More likely it is associated with microbial activity, 
 the irritation of the tissues caused by the excessive physical 
 exercise favouring their activity. 
 
 In most cases, possibly, there is a gonorrhoeal infection 
 at the time of coitus. The influence of labour has long 
 been regarded as a prominent factor. In the puerperium 
 all the conditions favourable to germ activity are present. 
 The woman is reduced in strength. The uterus is weakened 
 by its great exertion in delivery, the condition of its circula- 
 tion is greatly altered owing to the contraction and retrac- 
 tion of its musculature, and its tissues are below their 
 normal standard of strength owing to the puerperal retro- 
 gressive changes which take place in them. The inner 
 
 il 
 
 
 - 
 
 
1: 
 
 152 THE GENITAL TRACT AND MICRO-ORGANISMS. 
 
 surface affords a large absorbing area; the placental area 
 presents a number of opened blood sinuses in which blood 
 clots are formed ; blood clot often lies in the cavity ; the 
 cervix is often torn ; the perineum and vagina may be 
 bruised and lacerated ; portions of the placenta or mem- 
 branes may be left /;/ utero. 
 
 That the lacerations per se can start an inflammation is 
 not now believed. Were it not for germ infection, they 
 would heal by direct union or direct granulations, without 
 the development of inflammatory phenomena. 
 
 There are certain conditions in the puerperium which 
 may also predispose the uterus to infectivity, e.g. too early 
 rising, walking, or working, but whether these conditions in 
 themselves can lead to actual metritis is doubtful. One 
 thing i'i certain, namely, that in many cases these conditions 
 are followed by no disturbance wliatever. It is common to 
 find among the labouring classes those who systematically 
 rise early after childbirth and go to work, in whom no 
 inflammatory changes whatever follow. 
 
 Injuries resulting from operative measures may, by bruis- 
 ing, lacerating, or cutting the wall of the genital tract, afford 
 a nidus for the development of germs ; the irritation of a 
 pessary may act in the same manner. 
 
 The influence of certain general conditions, e.g. rheuma- 
 tism, malaria, scrofula, constitutional syphilis, probably plays 
 some part in certain pelvic inflammations, but we cannot at 
 present speak with any definiteness in regard to how they 
 act nor in regard to their relationship to microbial action. 
 They may certainly act in one way, namely, by depressing the 
 vitality of the tissues. 
 
 Regarding the n odes of action of the various germs it is 
 needless to speak. Various tissues are affected ; various 
 results produced ; these variations depending upon the 
 mode of entrance of the microbes, their virulence, the 
 nature of the soil on which they grow, the power of 
 resistance of the tissues. 
 
GONORRHCEA. 
 
 153 
 
 Gonorrhoea. — Special reference must be made to the 
 part played by gonorrhoea. 
 
 Since Noeggerath published his first paper in 1872 great 
 P^^tention has been given to the study of gonorrhoea as a 
 factor in the production of pelvic disease in women. In 
 Great Britain, Sinclair, and in Germany, Sanger, have been 
 most prominent in pointing out its importance. 
 
 A woman may acquire an acute gonorrhoea. In such a 
 case the gonococcus develops by selection in the mucous 
 glands of the urethra and urethral orifice, in the ducts of the 
 Bartholinian glands, and often in the mucosa of the cervical 
 canal. So far as is known, the vaginal wall is probably 
 proof against the activity of this germ unless its vitality be 
 impaired, or its epithelium thinned or cracked {vide p. 582). 
 
 In most cases the acute disease is set up in the cervix 
 and vulva at the same lime. Sometimes, however, as a 
 result of the contaminating coitus, the cervix may be at 
 first affected, and the vulvar region afterwards. In some 
 cases only the external parts are infected. 
 
 In any case, it is of great importance to note that when 
 all acute symptoms and signs have passed away, the disease 
 may still be present in the crypts about the urethral orifice, 
 in the ducts of the Bartholinian glands, and in the cervix. 
 
 In connection with gonorrhoeal infection, sometimes in 
 the acute stage, but more commonly after the acute stage 
 has passed away, inflammation may spread up the whole 
 mucosa of the uterus, may be found in the tube, ovary, or 
 in th.' peritoneum round about these. It may spread to 
 the bladder, ureters, and kidney. It may affect the Barthol- 
 inian glands. 
 
 Is the gcnococcus the cause of infecti'^" in these cases ? Do 
 the products of its growth merely fu ■ the activity of the 
 streptococcus and other important or'^amsms ? Is the infection 
 due to a mixed infection of gonoccccus and streptococcus, or 
 some ^thtr pathogenic germ ? 
 
 These questions cannot be answered with accuracy. By 
 
 •m. 
 
 : ii 
 
 iii 
 
 jj 
 

 ; 
 
 154 THE GENITAL TRACT AND MICRO-ORGANISMS. 
 
 many it has been believed that the gonococcus is capable 
 o'f carrying infection directly to all these different parts. 
 Now the tendency is to limit the range of its activity. 
 There are, however, great variations in opinion. One fact 
 seems to have been established, namely, that the products of 
 the gonococcus can so alter the secretions in the vagina 
 (rendering it neutral or alkaline) as to render it favourable 
 to the growth and activity of streptococci and other patho- 
 genic organisms. 
 
 Regarding the spread of an inflammation from the urethra 
 to the bladder and, it may be, up the ureter to the kidney, 
 it is believed that the infecting agents are streptococci, etc., 
 and not the gonococcus, the former having started on its 
 course in the favouring conditions produced by the action 
 of the latter in the urethra. 
 
 As regards the setting up of inflammation in the Barthol- 
 inian glands, some believe that the gonococcus may be 
 directly responsible, while others think that the infecting 
 agent is one of the other organisms referred to. Probably 
 each may be able to infect the gland. Certainly in some 
 cases the gonococcus may be found in the inflamed gland. 
 It might be expected to infect that tissue because the gland 
 is lined with a single layer of cylindrical epithelium, a favour- 
 able site for the gonococcus. 
 
 As regards the uterus, there seems little doubt that 
 inflammation may be set up both in the mucosa and in 
 the whole wall by the gonococcus. As to the frequency 
 with which this occurs one cannot speak with accuracy. 
 
 In many cases of uterine inflammation, which clinically 
 might be attributed to the influence of the gonococcus, the 
 germ cannot be found at all. No doubt, in some of these 
 cases, the infecting agent is some other organism, e.g. 
 streptococcus. 
 
 liut it must here be stated that Bunmi, (iottschalk, and 
 Immerwahr have recently reported that in a considerable 
 number of cases of uterine inflammation they could not 
 
il 
 
 GONORRHCEA. 
 
 »55 
 
 find aii}^ germs in the secretions from the uterus. This, 
 of course, does not necessarily prove that the cause of the 
 inflanmiation in these cases was not micro-organismal. 
 
 Neither is Menge's report conclusive, namely, that in the 
 examination of curettings from seventy-three cases of endo- 
 metritis, he was unable to find micro-organisms, save, in 
 some cases, the gonococcus and tubercle bacillus. 
 
 In some cases there may be an infection due to the 
 activity both of the gonococcus and of one of the other 
 germs. 
 
 As regards the tube, there is ample proof for believing 
 that the gonococcus may infect it and lead to inflammation. 
 A. Martin believes that in some cases it may reach the 
 tubes by way of the lymph channels or spaces in the 
 connective tissue of the parametrium instead of travelling 
 along the mucous tract. Mixed infection may occur in 
 some cases. 
 
 As regards the peritoneum, Sanger believes that the gono- 
 coccus is only capable of setting up localised pelvic inflam- 
 mation, e.g. perisalpingitis, periovaritis. He thinks that it 
 cannot initiate a widespread peritonitis, but regards this as 
 being due to mixed infection, the active agent being strepto- 
 coccus, or some other organism. The gonococcus does not 
 appear to survive long in the peritoneal cavity. It is also 
 believed by many that cellulitis is not due to the gono- 
 coccus infection directly, but to mixed infection ; I mean, 
 in cases where it follows gonorrhoeal infection. As regards 
 the ovary, it is also believed that the gonococcus may infect 
 it from the tube, and set up inflammation. 
 
 Sanger lays great stress upon the marked liability of preg- 
 nant and puerperal women to acute gonorrhceal infection ; 
 and, also, on the tendency to the development in these 
 states of an acute exacerbation of what was previously a 
 slight infective inflammatory process. Thus a latent condi- 
 tion may develop into an acute outbreak in pregnancy or 
 the puerperium without any fresh infection occurring. 
 
156 THE GENITAL TRACT AND MICRO-ORGANISMS. 
 
 Sanger points out that in the puerperium a special variety 
 of acute inflammation of the tubes and ovaries of a pure 
 gonorrhoea! nature may be due simply to a recrudescence of 
 an old gonorrhoeal trouble, without any new infection. 
 
 It must, however, be remembered that similar phenomena 
 may be produced by the action of septic organisms. These 
 always find more favourable conditions for development 
 where there has been a latent gonorrhoea. Possibly, there- 
 fore, some of the cases referred to by Sanger are of this 
 nature. 
 
 The particular work of Noeggerath was to point out the 
 importance of " latent gonorrhoea in the male " as a factor 
 in the production of various diseases in the female pelvis, 
 especially endometritis, salpingitis, ovaritis, and localised 
 peritonitis. He pointed out, what is now generally recog- 
 nised, that the male urethra may remain the seat of a latent 
 power of infection long after all apparent signs and symptoms 
 of acute gonorrhoea have passed away. This power resides 
 in a discharge produced by the remains of the original 
 gonorrhoeal infection, and is probably limited to the crypts 
 of the mucous membrane. 
 
 The excitement of marriage, of alcoholic indulgence, or 
 of over-fatigue, may stimulate these areas of latency into 
 renewed activity, and, as a result, the woman, after coitus, 
 may be infected in the manner which I have described. 
 
 The manner in which this is brought about is not clearly 
 known. In many of these discharges from the male 
 urethra, no gonococci can be found. Very probably in 
 such instances the discharge may act by modifying the 
 vaginal or cervical secretion, as to afford a suitable nidus 
 for the streptococci or staphylococci, which spread up- 
 wards, causing the various disturbances to which I have 
 alluded. 
 
 Very often a perfectly healthy woman is infected this 
 way at the time of her marriage, developing various forms 
 of pelvic trouble soon afterwards. 
 
TUBERCLE BACILLUS. 
 
 157 
 
 The part played by the Bacterium coli commune is dis- 
 cussed in connection with peritonitis {vide p. 300). 
 
 Tubercle bacillus. — Tuberculosis in the genital tract may 
 be set up in a variety of ways. 
 
 1. It may be primary, i.e. the bacilli may enter from the 
 outside by way of the vagina, being introduced by dirty 
 instruments, by examining fingers, by sleeping with a tuber- 
 cular person, by coitus with a man suffering from genito- 
 urinary tuberculosis. In such cases, the vagina and cervix 
 may be first affected, the disease spreading afterwards along 
 the uterine and tubal mucosa ; or the upper genital tract 
 may sometimes be first attacked, according to Whitridge 
 Williams, the bacilli entering a denuded surface on the 
 vaginal wall and being carried up by the lymphatics. 
 
 2. The genital organs may become affected by the direct 
 spread from neighbouring tuberculous areas, e.g. tubercu- 
 losis of bladder or bowel ; ulcers may perforate or abscesses 
 burst, leading to fistulous communications. 
 
 Williams states that one of the most frequent sources of 
 genital tuberculosis is tubercular peritonitis. Weigert has 
 shown that in this disease the bacilli which become free in 
 the peritoneal cavity tend to sink into the pelvis, setting up 
 infection ; they are there in the best position to be swept 
 towards and into the tubes, and they may be undoubtedly 
 carried into the latter, setting up disease, without infecting 
 the pouch of Douglas at all. 
 
 3. The bacilli may be introduced directly into the vagina 
 when the patient has tuberculosis in some other region, e.g. 
 urinary tract, intestines, lungs, the infection spreading from 
 the discharges. 
 
 Hegar has pointed out that genital tuberculosis is rare in 
 childhood and after the climacteric. 
 
 Infection by men suffering from genito-urinary tuber- 
 culosis is of considerable interest. A good many cases 
 have been noted in which tubercular epididymitis has given 
 rise to infection. There are instances also in which men 
 
 V' 
 
 till 
 
158 THE GENITAL TRACT AND MICRO-ORGANISMS, 
 
 
 suffering from pulmonary tuberculosis have infected the 
 genitals of their wives, but it is not known whether, in such 
 cases, the tubercle bacilli are contained in the semen. 
 
 Landou/.y and Martin mixed the semen of a guinea-pig 
 which had died of tuberculosis, with salt solution, and 
 injected the mixture into the peritoneal cavity of fifteen 
 guinea-pigs ; five died of tuberculosis. Curt Jani found 
 very few bacilli in apparently healthy testicles and prostates 
 of persons with tubercular phthisis. Gartner states, in 
 reference to Jani's description, that in tubercular patients, 
 before death occurs, the bacilli may spread to various parts 
 of the body, and hence in this stage may often be found in 
 the blood. 
 
 Spano injected semen from a tubercular man into the 
 abdominal cavity of eight guinea-pigs, and produced tuber- 
 culosis in six cases. 
 
 In two other cases, by injecting it into the vagina, genital 
 tuberculosis was caused. 
 
 Mafucci injected large doses of bacilli into the jugular 
 vein of a dog, and found them afterwards in the semen of 
 the animal. 
 
 Rohlff, however, introduced semen from a tubercular 
 man into the anterior chamber of the eyes of goats and 
 rabbits by means of a needle puncture, and got no results. 
 The amount of virus introduced was, however, very small 
 in these cases, and goats are not very susceptible to tuber- 
 culosis, so that these experiments are inconclusive. 
 
 Westermayer introduced testicular tissue from a tuber- 
 cular patient into the peritoneal cavity of rabbits without 
 setting up tuberculosis, but he was not able to distinguish 
 tubercle bacilli on microscopic examination of the testicles. 
 In a case of acute miliary tuberculosis, in which bacilli were 
 found in the testicle, injections of portions of it into the 
 peritoneal cavity caused tuberculosis in the rabbit. Walther 
 examined several testicles in cases of phthisis and found no 
 tubercle bacilli in them. Gartner thinks that they are very 
 
TUBERCLE BACILLUS. 
 
 >59 
 
 scanty in the semen in such cases. He injected tubercle 
 bacilli in the trachea and lungs of male guinea-pigs, setting 
 up infection, and after three or four days obtained semen 
 from their testicles. In thirty-two cases he found tubercle 
 bacilli only in five, and the semen in these few instances, 
 when introduced into the peritoneum of other animals, 
 set up only a mild form of tuberculosis. In another set of 
 cases he set up tuberculosis in the testicle by local injection, 
 and found that in 50 per cent, of the animals into which 
 he introduced the semen severe tuberculosis was set up. 
 (Partner, therefore, believes that genital tuberculosis in the 
 male is a very much more serious danger for the female 
 than distant tuberculosis. 
 
 The various parts of the genital tract, including the 
 ovaries, may be affected, though the vulva and vagina are 
 very rarely attacked. Sometimes a mixed gonorrhccal and 
 tubercular infection may take place. Pyosalpinx may 
 develop in tubercular salpingitis, probably associated with 
 a mixed septic infection. 
 
 s 
 
 i' I 
 
 
 {A 
 
 ' ''f 
 
 ■■I 
 
CHAPTER VII. 
 
 CASE-TAKING. 
 
 The examination of a woman suffering from one of the 
 diseased conditions peculiar to her sex is sometimes a very 
 simple matter, but very often it is a difficult and unsatis- 
 factory process. A physician may investigate the state of 
 her lungs or nervous system with comparative ease, but 
 when the region of the pelvis enters into consideration, 
 exceptional tact and skill are, in many cases, essential to 
 the acquirement of all the information that may be desired. 
 It is most important that the investigation should be con- 
 ducted so that the patient is convinced that she is being 
 treated with the utmost consideration and delicacy. No 
 definite method can be adopted for all cases. It is neces- 
 sary to vary the method of procedure according to the 
 nature of the case, the temperament and condition of the 
 woman, as well as other factors. There must always be a 
 judicious blending of the suaviter Siud forfiter. A physician 
 may possess great knowledge regarding the pathology and 
 treatment of diseases of women, but he will not make great 
 headway in the practice of gynecology unless he ever appre- 
 ciates the subtleties and peculiarities of the psychical 
 organisation of women. Delicacy, tact, patience, and 
 judgment must be brought into employment. Thorough- 
 ness, also, must be particularly enjoined. Owing to the 
 peculiar difficulties of gynecological examination, there is a 
 constant temptation to be satisfied with an imperfect ac- 
 quisition of facts, and there is no department of medicine 
 
METHOD. 
 
 i6i 
 
 in which more serious mistakes may ensue from want 
 of thoroughness, than in gynecology. Finally, downright 
 honesty should be the motto of the physician. There is 
 no sphere in which there has been more dishonest practice, 
 and it is not out of place to utter a strong protest against 
 the crime practised by those who, for the sake of gain, 
 trade on the fears which naturally fill the minds of many 
 women when their reproductive apparatus is out of order, 
 and who elevate into an unnecessary importance conditions 
 which are but trifling. 
 
 In all first-class schools of medicine, students are taught 
 to study their dispensary and hospital cases according to 
 a systematic plan. Such a method is an admirable and 
 necessary one on account of the training it gives, but it is 
 needful to remind the student that, in private practice, the 
 case-taking card may not, in many cases, be rigorously 
 followed ; he may vary his method for particular reasons in 
 special instances. 
 
 The following plan is a somewhat modified form of the 
 card used in the University of Edinburgh — drawn up by 
 Professor A. R. Simpson : — 
 
 ANAMNESIS. 
 
 1. Name; Age; Occupation; Residenx'e; Married, Single, 
 
 OR Widow; Date of Admission. 
 
 2. Complaint and Duration of Illness. 
 
 3. General History of — {a) Present Attack ; {li) Previous 
 
 Health ; {c) Diathesis ; [d) Social Conditions and Habits ; 
 {e) Family Health. 
 
 4. Sexual History. 
 
 ( I ) Menstniation — 
 
 A. Normal — {a) Date of Commencement ; {b) Type ; 
 (f) Habit- 
 Duration. 
 
 Quantity ; 
 {({) Date of Disappearance. 
 
 B. Morbid — (a) Amenorrhoea ; {b) Menorrhagia ; {c) Dys- 
 menorrhoea. 
 
 II 
 
 1 ''^ 
 
 
 t 
 
 ^ !' 
 
 m 
 
 
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■? 
 
 163 
 
 CASE- TAKING. 
 
 (2) I ntcrmensinial Discharge— {a) Character; (/i) Quantity. 
 
 (3) Pregnancies— (a) Number ; {b) Dates of First and Last ; 
 
 [c] Abortions ; [ti) Character of Labours ; {e) I'uerperia ; 
 (/) Lactations. 
 
 5. Local Functional Disturhances — (a) Bladder ; {h) Rectum ; 
 
 (r) Pelvic Nerves and Muscles. 
 
 6. Gknkral Functional Dkranoements— («) Nervous System ; 
 
 {h) Respiratory System ; (r) Circulatory System ; {li) Digestive 
 System ; {e) Emunctories. 
 
 PHYSICAL EXAMINATION. 
 
 1. General Appearance and Configuration. 
 
 2. Mamm^:. 
 
 3. Ahdomen — {a) Inspection ; (/;) Palpation ; {c) Percussion ; (^/) Aus- 
 
 cultation ; {e) Mensuration. 
 
 4. External Genitals. 
 
 5. Per Vaginam— (a) Orifice; {b) Walls and Cavity; {c) Roof; 
 
 {(T) Os and Cervix Uteri. 
 
 6. Bimanual Examination (Abdomino-Vaginal, Recto-Vaginal, 
 
 Abdomino-Rectal, Abdomino- Recto- Vaginal, Abdomino-Vesico- 
 Vaginal) — 
 
 (i) Uterus — {a) Size ; (/;) Shape ; {c) Consistence ; {il) Sensi- 
 tiveness ; {e) Position ; (/) Mobility ; {g) Relations. 
 
 (2) Fallopian Tubes. 
 
 (3) Ovaries — {a) Size ; {b) Situation ; (r) Sensitiveness. 
 
 (4) Peritonetun and Cellular Tissue. 
 
 (5) Bladder. 
 
 (6) Rectum. 
 
 (7) Pelvic Bones. 
 
 7. Inspection of Vaginal, Rectal, and Vesical Cavities. 
 
 8. Use of — (a) Speculum ; {b) Volsella ; {c) Sound ; {d) Dilators ; 
 
 {e) Curette ; (/) Aspiratory Needle. 
 
 9. Physical Changes in— (a) Nervous; {b) Respiratory; (<r) Cir- 
 
 culatory ; {(T) Digestive ; {e) Emunctory Organs ; (/) Skin ; 
 (^'•) Bones. 
 
 DIAGNOSIS. 
 
 PROGNOSIS. 
 
 TREATMENT. 
 PROGRESS AND TERMINATION. 
 
ANAMNESIS. 
 
 '63 
 
 ANAMNESIS. 
 
 It is most irnportant that this plan should be carefully 
 mastered by students. It is not to be hastily crammed at 
 the last moment, immediately before their clinical examina- 
 tions, nor to be held in their hands while taking a case, and 
 used as a mere mechanical guide of procedure. A thorough 
 mastery of the card involves a wide clinical knowledge, and 
 the various divisions are arranged in a form convenient to 
 the grouping of the details of information which we obtain 
 for comparison with the records of past experience. 
 
 In Division I. there are some points of importance to be 
 noted by students. The age of the patient must be deter- 
 mined ; and the special disturbances which are found at 
 puberty, during the period of sexual activity, and at the 
 menopause, must be borne in mind. The occupation must 
 be known ; chiefly, in this connection, must we inquire 
 whe*^' er the woman has too long hours, lifts heavy weights, 
 stanas too much, or works under unfavourable conditions. 
 It is equally important, also, in certain other cases, to know 
 whether the woman is one of those who have too little to 
 do, or spends her life in idleness and excessive indulgence. 
 The place of residence is noted as a matter of routine, but 
 in certain cases it may be of some importance in relation 
 to the health ; thus, the patient might live in a district 
 where rheumatism is prevalent, or she might have spent 
 some time in a tropical climate. 
 
 In finding out whether the patient is married, single, or 
 widowed, tact is necessary. Sometimes the patient volun- 
 teers the information, but generally it must be elicited. 
 Awkward blunders are often made by students, e.g. asking 
 a widow if she has pain on coitus, or a newly-married 
 woman as to when she last had a child. It must be re- 
 membered, also, that widows and unmarried may come as 
 patients either in a state of pregnancy or suffering from 
 some condition related to an immoral relationship. 
 
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 IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
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 1.25 
 
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 2.5 
 
 20 
 
 1.8 
 
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 Photographic 
 
 Sciences 
 Corporation 
 
 23 WEST MAIN STREET 
 
 WEBSTER, N.Y. 14580 
 
 (716) 872-4503 
 
L<P 
 
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 1 64 
 
 CASE-TAKING. 
 
 The examination of such a case must be conducted most 
 cautiously. The physician may be suspicious, but he must 
 be very careful in his questions lest he should be mistaken. 
 Moreover, he must be prepared for deliberate falsehood 
 from many such cases, and he must take care not to be 
 thrown into error. Also in cases where the physician 
 suspects some venereal complication, he must frame his 
 questions in the most careful manner, in order not to arouse 
 the suspicions of the patient, who may be an entirely 
 innocent sufferer. 
 
 Division III. refers to some points which must be inquired 
 into with care. The history of the i'.lness of which the 
 patient complains must be obtained most carefully. In 
 some cases this is definite and distinctive enough to jus- 
 tify an immediate diagnosis, but in the great majority of 
 gynecological troubles the indefiniteness of the history is 
 most perplexing to the student. In the general run of cases 
 previous health is not minutely inquired into, but it is 
 necessary that nothing important be overlooked ; e.g. if the 
 patient had had rheumatic fever some years previously, the 
 neglect to find this out and to examine the heart might lead 
 to very serious consequences. Moreover, if the patient be 
 married, it is most important to compare her health before 
 with that after marriage. 
 
 Diathesis and family health are not particularly considered 
 in a large number of cases, but sometimes they may have 
 an important bearing. Hereditary tendencies must some- 
 times be noted, e.g. mental diseases, tuberculosis, tumour- 
 formation, haemophilia. The social condition and habits 
 of life are important points for consideration. Over-work, 
 imperfect feeding, poverty, bad sanitary conditions, luxury, 
 vicious living, f^are, and worry have an important bearing 
 on many cases. v ^ 
 
 Division IV. requires to be considered with the greatest 
 care and exactness. It deals with the sexual history. The 
 normal menstrual history must be inquired into, and it is 
 
 J 
 
 I \ 
 
ANAAfNESIS, 
 
 i«5 
 
 important that the student bear in mind all the variations 
 found in connection with normal menstruation. I note 
 some of these. < 
 
 The date or commencement or period of puberty 
 occurs at varying periods. It is influenced by various 
 factors. 
 
 Climate. — In temperate regions it occurs at the age of 
 14 or 15; in cold countries, at a later period; in warm 
 ones, earlier. 
 
 Environment. — Rich living and city life tend to the 
 development of an earlier commencement. 
 
 Race. — Racial characteristics are preserved, e.g. English 
 girls born in India menstruate as do those of their race, not 
 at an early period like the Indians. 
 
 Heredity. — In some families peculiarities as to menstrua- 
 tion may be transmitted from generation to generation. 
 
 It must be remembered that there are variations in the 
 method of the establishment of the function of menstrua- 
 tion, e.g. it may take place gradually, intermittently, or 
 suddenly. In some rare cases in our country menstruation 
 may begin in childhood, at 8 or 10, or may be delayed 
 until the age of 20, 22, or even 25. And these extremes 
 may be found where the girl is quite healthy. In most 
 cases of delay, however, there is some pathological cause. 
 In particular, the serious condition of malformation of the 
 genitals, e,g. atresia vaginae, must be kept in mind. 
 
 Tyi)e refers to periodicity. It is the interval from the 
 Commencement of one to the commencement of the next 
 menstruation (not, as is often said by students, " from the 
 end of one to the beginning of the next "). In most cases 
 the twenty-eight day type is found. In a small proportion 
 the thirty day, the twenty-one day, and a few other types 
 are found. In the great majority of cases, the type is 
 regular, the patient being healthy, i.e.^ the number of days 
 is always the same. But it must be remembered that in 
 some women irregular types are found not associated with 
 
 /» 
 
1 66 
 
 CASE-TAKING. 
 
 ■•■ \ 
 
 any unhealthy state. As an example, I may mention one 
 case in which throughout a number of years the woman 
 had a mixture of twenty-one, twenty five, and twenty-eight 
 day types. v; ^^ 
 
 Habit refers to the duration and quantity of the flow. 
 Normally, considerable variations are found. Thus it may 
 last from two to eight days ; occasionally for nine days, the 
 woman being quite healthy. A very large number of 
 women have a dischai^^e of blood for about a week. The 
 amount of discharge lost is normally from 3 to 9 oz. 
 Generally, 6 or 8 oz. are lost. The estimation of the 
 quantity by means of diapers is unreliable, because of the 
 variations in the habits of women as regards cleanliness. 
 Some wear half a dozen where three would suffice, while 
 others make three or four perform the need of eight or ten. 
 Each woman, in a state of health, loses a fairly constant 
 quantity at each period. On the average, perhaps, three or 
 four diapers are used in twenty-four hours. 
 
 The date of disappearance of the menstrual function is 
 a variable one. This cessation is one of the phenomena 
 met with at the menopause, a period also known as the 
 critical time, the turn of life, the change of life, or the 
 climacteric. In about 50 per cent, of women, it takes 
 placs between 45 and 50; in about 25 per cent, between 
 40 and 45 ; in about 12^ per cent, before 40 ; in about \2\ 
 per cent, after 50. In a few cases it may occur between 
 20 and 30, or as late as between 60 and 70. These 
 advanced periods have been mentioned, but it is doubtful 
 if they were not pathological. It is very rare to find a 
 woman in a normal condition menstruating after 55. 
 
 Stoppage of menstruation is not synonymous with change 
 of life. It is merely one of many phenomena. The change 
 of life may take place quickly or slowly. Usually its dura- 
 tion is from one to three years. It is most important that 
 the student should bear in mind the various methods in 
 which the menstrual function ceases, whether gradually, 
 
 >-v< 
 
 I 
 
 l\ 
 
ANAMNESIS. 
 
 167 
 
 suddenly, or intermittently ; and he should remember the 
 diseases which are apt to occur at this period of life, and 
 which may alter the normal menstrual condition. 
 
 It is often important to compare the menstrual function 
 in the single and married state of the patient. 
 
 After the study of the normal, the morbid menstrual 
 history should be investigated. It is of great importance 
 that, at this stage, the student should be able to make a 
 mental summary of the causes of the various abnormal 
 conditions to be investigated. 
 
 Amenorrhcea means diminution or cessation of the mens- 
 trual flow. Students, as a rule, state in examination that 
 it is " stoppage of the flow " ; this is only a partial answer. 
 A woman who normally menstruates for eight days, but 
 who has gradually altered so as to menstruate for two 
 days, is amenorrhceic, just as surely as if she had stopped 
 altogether, 
 
 Menorrhagia means increased menstrual discharge, and 
 may be expressed in terms of quantity or duration, or of 
 both. 
 
 The variations normally found in women must be borne 
 in mind. What is abnormal for one, may be normal for 
 another. 
 
 Dysmenorrhoea means pain associated with the menstrual 
 flow. Normally, in a certain number of cases no pain or 
 discomfort is felt ; in the majority of cases, a dull backache 
 is complained of. The pains may be sharp or dull, 
 dragging, down-bearing, or labour-like, and may be in the 
 loins, in the small of the back, in the pelvis, or shooting 
 into the thighs. Pains may be felt at different times, 
 namely, for a day or two before the flow commences, 
 ceasing at the commencement \ for a day or two before as 
 well as for the first day or two of the flow; during the 
 first day or two of the flow only ; during the whole extent 
 of the flow ; during the last two or three days of the flow ; 
 and for a day or two after the stoppage of the flow. 
 
 v'J 
 

 1 68 
 
 CASE-TAKING. 
 
 InteriDenstrual discharges are of various kinds. I v 
 
 Metrorrhagia means uterine haemorrhage occurring at 
 times other than the menstrual periods. In this connection 
 must be remembered the irregular discharges of blood often 
 found during the period of puberty before menstruation 
 is well established, and also during the period of the 
 menopause. The irregularity of type in certran women in 
 a state of health must also be borne in mind. 
 
 Leucorrhoea is the most common intermenstrual dis- 
 charge. In its best-known form it is called popularly 
 "whites." This discharge may proceed from the vulva, 
 bladder, vagina, cervix, or body of uterus. It may be variously 
 coloured, e.g. white, grey, yellow, green, etc., according to 
 whether urine or blood be mixed with it, or according to 
 the nature of the germs which may be growing in it. It is 
 mucopurulent, the constituent elements varying in different 
 cases, or it may be watery and acrid. It may be odourless, 
 or may have an odour, which in some cases may be ex- 
 tremely bad. The discharge may in some cases be mixed 
 with blood or urine. 
 
 The pregnancy history must be carefully considered. It 
 is important to know the number of pregnancies, especially 
 in relation to the duration of married life. Too frequent 
 conception is a serious factor in several diseased conditions. 
 The date of the first and last pregnancy must be known ; 
 conception, before nubility is well established, is a condition 
 whicn may lead to ?isturbed health. 
 
 It is especially necessary to know the abortion history of 
 the patient, for to abortion and its consequences much 
 ill-health in women is due. The character of the labours 
 must be known, e.g. whether they were easy, prolonged, 
 difficult, or whether they required the assistance of the 
 physician. It is necessary not to be misled by the patient's 
 statements in regard to this point. Often a patient will 
 state that she had a bad labour, or perhaps will say that 
 instruments were used when she has only had chloroform. 
 
ANAMNESIS. 
 
 169 
 
 It is also necessary to inquire as to how the patient 
 recovered from her labours — whether she had suffered from 
 pelvic inflammation during the puerperium, whether she 
 rose too early, worked too soon, or carried her baby much. 
 Some important gynecological troubles date from an ab- 
 normal puerperium. 
 
 Lactation has an important bearing on certain conditions, 
 and the physician must know whether the patient nursed 
 her children, and for what length of time. 
 
 Coitus must be inquired into in some cases. It should 
 only be done when absolutely necessary, and with the 
 greatest caution and delicacy. It may sometimes be diffi- 
 cult to elicit facts regarding some abnormal state, e.g. 
 dyspareunia, even though the patient has come to consult 
 the physician for nothing else. Coitus may be impossible 
 in certain cases. In the general run of such cases, the 
 condition is made known to the physician within a few 
 weeks or months of marriage. The cause may lie with 
 husband or wife. If with the latter, toughness of the 
 hymen, malformation, vaginismus, or other conditions may 
 be found. If the condition develops after some extent 
 of married life, other causes must be thought of, e.g. 
 inflammatory conditions, new-growth formation, etc. 
 
 Excessive coitus may have an important bearing on 
 certain conditions, but it is difificult tc get information on 
 this matter in many cases. Questions must be asked with 
 the greatest delicacy, but they are rarely necessary. 
 
 Sometimes a physician may suspect that a woman is 
 doing injury to herself by using methods for preventing 
 concepdon. It is difificult to find out the truth in such 
 cases. Women who are guilty of this habit will readily tell 
 falsehoods to a doctor. 
 
 An important abnormal condition to be considered is 
 dyspaxeimia, difficult or painful coitus. This condition is a 
 most important one in relation to the health and happiness 
 of a woman. The causes to be kept in mind are many, 
 
170 
 
 CASE-TAKING. 
 
 \ 
 
 e.g. awkward attempts at coitus, disproportionate size of the 
 male organ and vagina, imperfect development of the female 
 parts, inflammatory conditions in vulva, vagina, uterus, 
 pelvic perito) . ^um, cellular tissue, ovaries, and tubes ; dis- 
 placements Oi uterus, prolapse of ovaries, urethral caruncle, 
 fissures of ostium vaginae, or of anus, ulcers of rectum, piles, 
 coccygodynia, tender carunculae myrtiformes, vaginismus 
 from whatever cause. ■ ^ . . 
 
 Local functional disturbances of bladder, rectum, pelvic 
 nerves, and muscles, form a very important field for 
 investigation. ^ • 
 
 Very often the bladder symptoms are the most valuable 
 in leading the physician to a diagnosis. To neglect this 
 viscus may lead to very serious error. 
 
 The state of the rectum must be known. The frequency 
 of defaecation shoul*^. be found out. Often women will state 
 that they are all '.ight when the bowels move every three or 
 four days. If diarrhoea is present, its duration and nature 
 should be investigated ; sometimes it is caused by the 
 irritation of an overloaded bowel. The various causes of 
 these symptoms must be remembered, especially new 
 growths inside and outside the bowel ; ulcerations, simple 
 or malignant ; and pressure from various conditions, e.g. 
 retroflexed and enlarged uterus, haematocele, inflammatory 
 deposits. Pain associated with defaecation must be inquired 
 into. It may be found before, during, or after the act, and 
 may be due to anal fissure, ulcer, malignant disease, etc. 
 Mucus or blood may be found in the motions, and the 
 causes should be borne in mind, e.g. ulceration of bowel, 
 new-grov,'th formation, piles, and other causes. 
 
 Disturbed function in the muscles which are in the pelvic 
 floor is to be investigated. There may be a spasmodic con- 
 dition of some, e.g. the sphincter vaginae. But the important 
 points to consider are weakness and solution of continuity, 
 s.g. rupture of the perineal body. The most frequent cause 
 of these is to be found in connection with child-bearing. 
 
 r\ 
 
ANAMNESIS. 
 
 171 
 
 The state of the pelvic nerves is in the great run of cases 
 only considered in regard to the production of pain, which 
 is the commonest symptom among gynecological patients. 
 This symptom may be but one of a series of hysterical 
 phenomena, but it is often due to inflammation in uterus or 
 appendages, peritoneum or cellular tissues, pressure of new 
 growths or other swellings. But the patient may also com- 
 plain of numbness, cramps, and hindered movements in 
 the lower limbs. • 
 
 The last Division dealing with functional derangements of 
 the various systems of the body requires a little attention. 
 
 In a great many gynecological troubles, no routine exam- 
 ination is made of these systems. Perhaps too often is 
 there carelessness in this direction, and it may be necessary 
 to warn the physician in regard to it. It is of the utmost 
 importance that no condition be overlooked which might 
 have some bearing in relation to the symptoms of which the 
 patient complains, or to the course of the affection. 
 
 For example, a case with symptoms pointing to cystitis 
 has been treated as a purely local affair, and it has turned 
 out afterwards that the symptoms were really due to tuber- 
 cular disease of the kidneys. 
 
 Of all the systems, I desire particularly to point to the 
 nervous and alimentary^ as being of chief importance. The 
 disturbances of the nervous system known as neurasthenia 
 and hysteria, in all degrees of their manifestations, must be 
 kept in mind in the consideration of every gynecological 
 case. 
 
 In very many cases symptoms are referred to the pelvis, 
 which have no local explanation, but which are merely part 
 of ar extensive range of abnormalities due to the abnormal 
 nervous state. Or, in such a state, pelvic symptoms which 
 have been slight may become enormously exaggerated. 
 
 Much error has been committed in practice by concen- 
 trating attention upon the local and forgetting the general — 
 the very worst possible course to pursue. Such a case, after 
 
172 
 
 CASE-TAKING. 
 
 having undergone various tinkerings in her genital tract 
 without improvement, may sink into a condition from which 
 only the most judicious treatment can raise her. 
 
 Various disturbances of the alimentary system, especially 
 dyspepsia and constipation, are to be incjuired into. The 
 relationship between these conditions and symptoms referred 
 to the pelvis is important ; also the relationship between 
 pelvic troubles and reflex disturbances of stomach and 
 bowel functions are matters cf the highest importance in 
 treating disease in women. Sympathetic or reflex symptoms 
 are very common. 
 
 PHYSICAL EXAMINATION. 
 " General Appearance and Configuration. 
 
 The physician should note while the patient is .valking, 
 sitting, or standing, or during the rest of the examination, 
 whether there are any deformities to be seen, e.g. of spine, 
 pelvis, or lower limbs. Such conditions are important in 
 relation to child-bearing. Abnormalities of gait and posture 
 should also be looked for ; also, pendulous belly, swellings 
 in the abdominal region. The condition of the face must 
 be noticed, e.g. it may indicate a neurotic temperament, 
 malignant disease, or some other trouble. 
 
 Mammae. .„,,,' 
 
 In examining the mammae, the following points must be 
 noted, namely, size, general or local swellings, amount of 
 fat, consistence, tenderness, venous enlargement ; the con- 
 dition of the nipple, whether prominent, retracted, tender, 
 fissured ; prominence of sebaceous glands around nipples — 
 the so-called tubercles of Montgomery. Pigmentation 
 should be noted; whether there be the primary areola 
 outside the former. The presence or absence of colostrum 
 or milk. In compressing the breast to make this out, use 
 
 ! \ 
 
PHYSICAL EXAMINATION. 
 
 «73 
 
 both hands, and gradually squeeze the gland from the 
 periphery to the nipple. 
 
 In some cases, e.g. unmarried girls in whom pregnancy 
 is expected, one may sometimes, at an early stage of 
 examination, desire to know the condition of the breasts. 
 In order not to arouse any suspicions on the part of the 
 patient, it is best not to squeeze the gland at once, but to 
 palpate it, inquiring for painful areas ; while so employed, 
 one may be able to find out whether any milk be present. 
 
 Abdomen. 
 
 For the examination of the abdomen, the patient must 
 lie on her back on the couch or examination table. In 
 exposing the skin-surface, two methods may be employed. 
 The most thorough is the following : — The patient loosens 
 the waist-fastenings of her dresses and shirts and lies on her 
 back, her body being co^'ered with a rug. Under this cover 
 the skirts are drawn down to the level of the pubes. The 
 upper margin of the rug is then placed just above the nions 
 veneris. The bodice and corsets are next loosened in their 
 lower part, and the chemise drawn up, so as to leave the 
 abdomen quite bare. A less thorough method is to draw 
 the patient's clothes up under the rug as she lies on her 
 back. The rug is then turned down, without exposing the 
 hairs of the mens veneris ; the skirts are pulled up by the 
 patient, and a considerable portion of the abdomen is 
 exposed. 
 
 Inspection. — The following points should be kept in 
 mind in looking at the abdomen : — The shape, general or 
 local swelling, state of nutrition, retraction ; the condition 
 of the umbilicus, i.e. whether it has the normal dimple, 
 whether flattened or projecting ; striae, old or recent, due to 
 stretching of the abdominal walls from various causes, e.g. 
 piegnancy, tumours, etc. ; pigmentation ; distension of veins 
 in wall ] pulsations ; influence of respiration on swellings ; 
 
V. 
 
 >74 
 
 CASE-TAKING. 
 
 movements of foetus in pregnancy, which may first be seen 
 about mid-term in thin-walled women ; movements of in- 
 testines in thin-walled women. 
 
 Palpation. — Patient's knees should be drawn up, and she 
 should breathe quietly with open mouth, or should sigh 
 deeply. The hands of the examiner should be well-warmed, 
 and should only gradually be applied to the abdomen. It 
 is best that the patient's bladder and rectum should be 
 emptied beforehand. 
 The palpation should be gentle though firm. If it be 
 
 desired to adopt the method of sud- 
 denly forcing the finger-tips into the 
 abdominal wall, it should not be 
 adopted until gentle palpation has 
 been done. Often if the patient be 
 forcibly palpated at first, she will 
 not relax the wall afterwards. 
 
 In some case? the whole abdomen 
 must be examined carefully, and the 
 student should not forget the nine 
 areas into which the abdomen is 
 divided. 
 
 By palpation we may gain in- 
 formation regarding the following : — - 
 Consistence of walls, state of nourish- 
 ment, tenderness, tension ; presence of tumours, their size, 
 nature, mobility, relation to respiration, attachment to abdo- 
 minal wall, relation to pelvis ; presence and nature of other 
 swellings, e.g. ascites, herniae, glandular enlargements ; fcetal 
 parts, ballottement. 
 
 Percussion. —It is important to bear in mind the neces- 
 sity of light as well as of forcible percussion. It is always 
 best that bladder and rectum she Id be emptied beforehand. 
 We gain information by this method regarding the size 
 and position of the viscera ; outlines of swellings and 
 the relations of intestines to them ; differential diagnosis 
 
 Fig. so. — Outline diagram 
 of tlie nine area.s into 
 which the abdomen is 
 divided. 
 
 ! \ 
 
PHYSICAL EXAMINATION. 
 
 »7S 
 
 between free abdominal fluid and tumours, e.g. ovarian or 
 fixed masses of abdominal fluid. 
 
 Percussion of the abdomen may be made while the 
 woman sits or lies ori her back or side. 
 
 Some recommend distending the bowel by gas or fluid in 
 order to make more evident its extent for the purpose of 
 comparison with some swelling under consideration. 
 
 Auscultation. — This method is applied to the abdomen 
 for the purpose of making out the followmg : — Foetal 
 movements, which may be heard several weeks before 
 the mother can feel theTi, foetal heart sounds, foetal heart 
 murmurs, funic souffle ; uterine souffle of pregnane ^ ; souffle 
 of fibroids ; pulsation of aorta ; friction sounds of roughened 
 peritoneal surfaces rubbing together ; gurgling murmurs due 
 to gas and faeces in the bowel, the succussion murmur, the 
 cracking sounds made by the bursting of small bubbles in 
 the intestine. 
 
 Some of these intestinal sounds are often mistaken for 
 friction sounds. . 
 
 Mensuration. — Measurements of the abdomen are made 
 chiefly with reference to the estimation of the size of 
 abdominal swellings, especially for the purpose of estimating 
 their increase or diminution in size during a period of weeks 
 or months. A measuring tape is generally sufficient, but a 
 cyrtometer, made of strips of flexible lead, may also be used. 
 It is necessary to miike definite measurements, namely, 
 from the ensitoun cartilage to the pubes ; from the umbilicus 
 ^o the ensiform and to the pubes ; from the umbilicus to 
 the anterior-superior iliac spines ; from the ensiform to the 
 anterior-superior spines ; around the body at the level of the 
 umbilicus — the greatest circumference ; from the tip of the 
 spine of a vertebra to the middle line in front. 
 
 In order that the comparisons from time to time may be 
 exactly made, it is necessary that the patient should always 
 be measured in the same position ; the bowels should 
 not be distended with gas and freces ; the diminution or 
 
V 
 
 176 
 
 CASE-TAKING. 
 
 increase of fat on the body wall should be taken into • 
 account. 
 
 In some cases a complete and satisfactory examination of 
 the abdomen can be made only when the patient is under 
 an ana~:thetic. 
 
 Examination of External Genitals. 
 
 It is not necessary to inspect the external genitals as a 
 routine practice. It should be done as little as possible 
 in ordinary consulting-room work. The patient is placed 
 on her side, her feet being opposite a window. She is 
 covered with a rug, and, after her knees are drawn up, the 
 clothes are pulled up under the rug, and the pudenda 
 exposed. 
 
 The lithotomy position may also be used, but only where 
 absolutely necessary. This is undoubtedly the most con- 
 venient position when an anaesthetic is employed. For 
 thorough examination of the parts, the labia must be 
 separated with the fingers. The following conditions should 
 be looked for : — Malformations, varix, oedema, pigmenta- 
 tion, discharges, inflammation, fissures, venereal or malignant 
 disease, swellings, injuries, state of the hymen, state of the 
 urethral orifice. The patient may be asked to cough or 
 bear down in order that the effect on the perineum or 
 vaginal walls may be noted. 
 
 Examination per Vaginam. 
 
 The patient is placed on her left side on a couch, a light 
 rug being thrown over body and lower extremities. She 
 should then bend up her knees, and the dress should be 
 drawn upwards somewhat under the rug. (It is always best 
 that the bladder and rentum should be empty during 
 examination.) The physician's hands should be thoroughly 
 cleaned. If the case is one in which there is some discharge 
 
 r» 
 
PHYSICAL EXAMINATION. 
 
 «77 
 
 of blood, they should be made aseptic. The first two 
 fingers should be anointed with vaseline, oil, glycerin, or 
 soap and water, and are directed under the rug, bent into 
 the palm of the hand in c der not to soil the patient's 
 clothes, and carried to the fold between the buttocks. The 
 examiner mus': avoid the region of the clitoris. The student 
 must be particular to begin well to the back in the region of 
 the anus, and to pass the fingers carefully forwards. When 
 the anterior edge of the perineal body is reached, both 
 fingers may be at once inserted into the introitus vagin?e, if 
 there be no doubt that it is large enough — e.g. in a multi- 
 para. In a doubtful case— ^.^. in a nullipara — only the 
 forefinger should be at first used. In introducing the 
 finger-tips they should not press the anterior parts against 
 the symphysis, and the clitoris should not be touched. 
 
 In passing the fingers upwards, they should be directed 
 into the hollow of the sacrum, the perineum being pressed 
 backwards in avoidance of the anterior delicate structures. 
 In a case where the introitus is small, it is often advisable 
 to ask the patient to bear down strongly while the finger is 
 gradually pushed upwards. 
 
 The following points are to be borne in mind during the 
 examination : — size and tenderness of the introitus vaginae ; 
 condition of hymen or carunculae myrtiformes ; integrity of 
 perineum ; abnormal or diseased conditions of external 
 genitals ; size, temperature, moisture, rugosity, smoothness, 
 distensibility of vaginal walls ; sensitiveness, swellings in or 
 outside the walls ; polypi or other structures in the cavity ; 
 solutions of continuity in the walls ; state of urethra, base 
 of bladder and ureters ; condition of rectum ; size and state 
 of cavity and outlet of bony pelvis. 
 
 The size, shape, and consistence of the vaginal portion of 
 the cervix are noted ; its mobility ; whether it is split or 
 intact ; whether it is abnormally directed. 
 
 The size, shape, and consistence of the os uteri are to be 
 made out. The condition of the fornix or vault of the 
 
 12 
 
178 
 
 CASE-TAKING. 
 
 vagina is to be noted, but it is to be borne in mind that the 
 investigation of conditions outside the vagina, which may be 
 in relation to the fornices, is best carried out by means of 
 the bimanual examination. 
 
 Of course the vaginal examination may be done when tne 
 patient is in the lithotomy position, but in the consultation- 
 room only the lateral position is necessary. \ 
 
 It is necessary to be careful with regard to the examina- 
 tion of certain cases. If a mistress demands a vaginal 
 examination of a servant who is suspected to be pregnant, 
 the phys' ^ian should refuse. If an unmarried woman, 
 having been accused of illicit connection, asks for an 
 examination and a certificate that she is not in the family- 
 way, it is best not to accede to har request. 
 
 Bimanual Examination.^ 
 
 This is the most satisfactory method of gaining informa- 
 tion with regard to pelvic conditions : — There are several 
 varieties of this method — e.g. abdomino-vesical, abdomino- 
 vaginal, abdomino-rectal, abdomino-vesico-vaginal, abdomino- 
 recto-vaginal, abdomino-recto-vesico-vaginal. The most 
 commonly employed is the abdomino-vaginal, and this will 
 be considered first of all. In every case the bladder and 
 rectum should be empty. 
 
 Abdomino-vaginal bimanual. — In consulting-room prac- 
 tice, the following method is the best to adopt. The 
 patient is placed on a couch on her left side, and the 
 vaginal examination performed, according to the method 
 just described. The fingers being still in the vagina, th;-^ 
 patient is asked to turn from the lateral to the dorsal posi- 
 tion. It is best hat the back should rest on a plane which 
 slopes upward somewhat towards the head. The knees 
 
 ^ The honour of first having pointed out the importance of the bi- 
 manual belongs to N. Puzos, a French accoucheur of the eighteenth 
 fentury. 
 
BIMANUAL EXAMINATION. 
 
 179 
 
 should be drawn up and well separated. The physician's 
 warmed left hand should be placed on the patient's 
 abdomen, the finger-tips at the umbilicus. The patient 
 should breathe quietly and deeply with her mouth open. 
 If she restrains her breathing she should be asked to make 
 deep sighs. ,. 
 
 This hand is then gradually pressed downwards and 
 backwards towards the inlet of the pelvis, the ulnar edge 
 rather than the surface being towards the abdomen. The 
 fingers of the right hand which are in the vagina are pushed 
 well jpwards until they touch the fornix and the cervix. 
 The last two fingers of this hand are flexed on the palm 
 or lie in the hollow between the buttocks. Students often 
 make the mistake of placing the outer hand on the sym- 
 physis and pushing downwards and backwards immediately 
 above it, in this way disturbing the position of the uterus. 
 
 The examination should be conducted in the most 
 systematic manner. 
 
 The uterus should at first be made out — its size, shape, 
 consistence, sensitiveness, position, mobility, and relation- 
 ships determined. 
 
 The Fallopian tubes and ovaries should be investigated 
 with regard to the same points. In normal cases, unless 
 the abdomen be very thin-walled, the tubes are not often 
 felt. 
 
 The peritoneum and cellular tissue wiihin reach of the 
 examining fingers should next be palpated in regard to 
 deposits, collections of fluid, tumours, old cicatrices, sensi- 
 tiveness. 
 
 The bladder may be palpated in regard to sensitiveness, 
 inflammations, thickenings, tumours, calculus, distension or 
 thickenings of ureters. 
 
 The anterior part of the rectum and the condition of the 
 recto-vaginal septum may, to a certain extent, be examined 
 by the vaginal fingers, but for thoroughness the recto-vaginal 
 examination should be made. 
 
 
 ') 
 
V, 
 
 i8o 
 
 CASE-TAKINC. 
 
 The condition of the brim of the cavity and of the outlet 
 of the bony pelvis may be made out — abnormal measure- 
 ments, deformities, enlargements of bone, shape, mobility 
 and tenderness of coccyx, condition of sacro-sciatic liga- 
 ments and levator ani muscles. 
 
 The student, in particular, should bear in mind the fol- 
 lowing points in making the abdomino-vaginal treatment : — 
 Through the anterior fornix one may feel for the body of 
 the uterus, the bladder, ureters, round ligaments j rarely a 
 pregnant Fallopian tube, a prolapsed ovary, a blood extra- 
 vasation, inflammatory effusions, may be found ; sometimes 
 a subperitoneal fibroid. When the uterus is retroverted, 
 coils of intestine will be found in the utero-vesical pouch. 
 
 Through the posterior fornix the following may be dis- 
 tinguished : — faeces or other swellings in the rectum ; blood 
 or inflammatory deposits in the peritoneum or cellular 
 tissue ; prolapsed tubes and ovaries, normal or enlarged 
 from varir)us causes ; retroverted body of the uterus ; fibroid 
 of po terior wall of uterus ; malignant growths ; ascites. 
 
 Thr* 'ejh the lateral fornices the state of the broad 
 ligament-., tubes, and ovaries may be investigated in regard 
 to cysts, tumours, inflammations, cicatrices, blood extravasa- 
 tions, etc. 
 
 Finally, it must not be forgotten that in the pelvis may 
 occasionally be found certain abdominal organs or growths 
 in connection with them, i.e. the kidneys or spleen ; also 
 growths of omentum, bowel, peritoneum, etc. 
 
 The abdomino-recto-vaginal examination is more valu- 
 able than the method just described, not only because the 
 condition of the rectum is investigated, but because the 
 rectal finger can explore the condition of the posterior part 
 of the pelvis so easily through the thin rectal wall. It is 
 not a pleasant method either for patient or physician, but it 
 should be employed in every case where the other bimanual 
 examination is not satisfactory. Having finished the 
 ordinary bimanual, the middle finger should be withdrawn 
 
BIMANUAL EXAMINATION. 
 
 i8i 
 
 from the vagina, and passed gradually into the rectum. It 
 should be pushed well up through the folds of the third 
 sphincter, i \ in. above the anus ; these sometimes obstruct 
 the finger. 
 
 The abdomino - vesical and abdomino - vesico - vaginal 
 
 examinations are made chiefly for the investigation of 
 
 bladder conditions, and will be considered later (p. 184). 
 
 The abdomino-recto-vesico-vaginal examination is very 
 
 rarely employed, and is practically unnecessary. 
 
 The abdomino-rectal examination is important. It is 
 carried out in virgins when it is not considered advisable to 
 pass a finger through the hymen, in atresia or narrowness of 
 the vagina, in cases in which a tumour fills the vagina, in 
 shortness of the vagina, in malformations of the internal 
 genitals, for the purpose of studying the condition of coccyx, 
 rectum, or recto-vaginal septum. 
 
 The forefinger is used. It should be lubricated, and 
 gradually passed through the anus with a slightly rotatory 
 movement. With it the state of the sphincters, sensitive- 
 ness of the parts, the presence of fissures, tumours, piles, or 
 prolapsus may be made out. Above the anus the wide 
 ampulla is entered, and the third sphincter passed. The 
 following structures may then be palpated : — Posterior 
 vaginal wall, cervix, posterior part of body, utero-sacral and 
 broad ligaments, tubes, ovaries, posterior bony wall of 
 pelvis ; also, pathological conditions in these various 
 structures. 
 
 Those who have not been accustomed to this method of 
 examination are at first generally in doubt as to the relations 
 of the uterus ; the cervix may be mistaken for the body or 
 for a tumour. 
 
 Bimanual examination must be conducted with special 
 care in acute inflammatory conditions, in recent blood 
 extravasations, in distended tubes, in ectopic pregnancy, in 
 all thin-walled cysts, in advanced cancer of cervix or rectum. 
 
 In a great many cases a satisfactory examination can only 
 
l82 
 
 CASE-TAKING, 
 
 be obtained when the patient is ansesthetised, e.g. when she 
 is very fat, when she keeps the abdominal wall rigid, or 
 when there is much tenderness or pain. 
 
 When under the anaesthetic, the patient should be 
 examined in the dorsal or lithotomy position. 
 
 Fig. 51. — Genu-pectoral position. A speculum is placed 
 in the vagina. 
 
 Examination of Vaginal, Rectai,, and Vesical 
 
 Cavities. 
 
 Vagina. — The vagina may be exposed and examined by 
 means of the speculum. I will consider this method when 
 describing this instrument. The canal may be inspected 
 without the use of a speculum in two ways : — 
 
 {a) If the patient be placed in the genu-pectoral position, 
 and the introitus opened with the fingers, air rushes in, 
 and the canal becomes distended. (The physics of the 
 abdomen and pelvis have been fully worked out by 
 Simpson and Hart.) If the perineum be held back by a 
 finger, and the light from the window or an artificial light be 
 reflected into the vagina, its walls and the vaginal portion 
 of the cervix may be well seen. 
 
 ip) If the patient, while in the lithotomy position, have 
 
 \\ 
 
EXAMINATION OF VAGINA AND RECTUM. 183 
 
 her hips elevated somewhat, and the introitus be opened, 
 air rushes in and distends the vagina, while the uterus 
 gravitates towards the promontory. By means of a reflected 
 light the cavity may be examined while the labia are 
 separated and the perineum is pulled back. 
 
 Rectum. — {a) Digital method. — I have already described 
 the method of examination by means of a finger. Simon has 
 recommended the introduction of the whole hand. Such a 
 barbarous method is never necessary, and must be con- 
 demned. 
 
 (b) Stover's method. — The patient is placed on her side 
 with her knees drawn up, her buttocks being opposite the 
 source of light. One or two fingers are passed into the 
 vagina, and pressure is made downwards and backwards 
 through the posterior vaginal wall ; if, at the same time, 
 the anus be opened with the fingers of the other hand, 
 the anterior rectal mucosa can be everted and made 
 visible. 
 
 (r) Harfs method. — The patient is placed in the litho- 
 f^my position, and the pelvis elevated somewhat. If the 
 anus be opened with the fingers or with retractors, the air 
 rushes in, dilating the lower part of the rectum. The walls 
 may be examined by means of sunlight, or by reflected 
 artificial light. 
 
 (d) GenU'pedoral position. — Tn this position, if the anus 
 be opened, the air rushes in, distending the rectum. If the 
 anus be kept widely opened by means of the fingers, or with 
 retractors, the interior of the bowel may be studied by means 
 of sunlight, or by reflected artificial light. 
 
 {e) Use of the tubular speculum. — The rectal speculum is 
 of the tubular variety ; its inner surface should be a reflect- 
 ing one. On one side is a fenestra. The instrument may 
 be made of polished metal or of glass, silvered, and covered 
 with vulcanit*^. 
 
 It is best used while the patiei^ is in the lithotomy 
 posture. When it is passed through the anus, light is 
 
 f 
 
V 
 
 1 84 
 
 CASE-TAK'ING. 
 
 
 reflected into it, and it is rotated in order to bring different 
 portions of the wall into relation with the fenestra. 
 
 This method is not so satisfactory as the last two 
 described. 
 
 Bladder. — {a) In many cases some information may be 
 gained regarding the state of the interior of the bladder 
 by the ordinary abdomino-vagitial bimanual examination, 
 just described. 
 
 (b) Digital examination. — Vesical, abdomino-vesical, and 
 abdomino-vesico-vaginal. — The patient is chloroformed in 
 the lithotomy posture. The external genitals are thoroughly 
 washed and made aseptic. The urethra should be gradually 
 dilated until the index-finger can be passed. For this 
 purpose Hegar's dilators are valuable. The finger should 
 be lubricated with antiseptic vaseline. In this way the 
 state of the mucous membrane may be investigated, e.g. 
 with regard to inflammation, tumours, deposits of salts, 
 fistulas, presence of calculi. When the bimanual is 
 performed it should be noted that the body of the uterus 
 may be easily palpated, obscure conditions in front of 
 the uterus, and the state of the Fallopian tubes made out. 
 After the examination the bladder should be washed out 
 with an antiseptic lotion. 
 
 Some recommend cocain application to the urethra pre- 
 liminary to dilatation instead of a general anaesthetic. 
 
 It is best, in the adult, not to dilate the urethra beyond 
 I to I in. in diameter. Beyond this there is danger of 
 permanent incontinence. In young women of 15 to 
 20 years of age the limit should be f in. ; in girls 
 of 10 to 15 years it should be from \ ^o \\ in. Of 
 course, greater dilatation has been made, but there is 
 always risk. 
 
 if) Ordinary specular examination. — An ordinary small 
 tubular speculum with a reflecting inner surface may be used 
 for the examination of the bladder, the patient being placed 
 in the lithotomy position. Antiseptic precautions are used 
 
 t\ 
 
EXAMINATION OF BLADDER. 
 
 1 8s 
 
 and the urethra is dilated sufficiently to admit the speculum. 
 Light is reflected into the instrument. This is an unsatis- 
 factory method. The urine trickles into the end of the 
 speculum and the bladder walls fall over it, so that 
 it is difficult to examine the mucosa systematically and 
 thoroughly. The walls of the urethra may be studied by 
 means of a tubular speculum fenestrated on one side, as 
 recommended by Skene. 
 
 (d) Kelly's special method. — This is the most valuable 
 method. The patient's bladder is thoroughly emptied. 
 She is placed in the lithotomy position, and the urethra 
 dilated to the size necessary for the speculum required. 
 The hips of the patient are now elevated on cushions, from 
 12 to 1 6 in. above the table. A tubular speculum of 
 polished metal containing an obturator is now passed. 
 When the obturator is removed the bladder fills with air, 
 and balloons. Any fluid still in the bladder can be 
 sucked out with a syringe or with balls of cotton-wool. 
 Light is reflected into the specul i by a mirror placed 
 on the physician's forehead, from an electric lamp, an 
 Argand burner, an ordinary lamp or candle, the room 
 being darkened. Strong sunlight may also be used. By 
 moving the speculum the posterior wall and base of the 
 bladder may be studied. The surface, normally, is pale, 
 the network of vessels being distinct. The inter-ureteric 
 ligament shows by a slightly raised transverse fold. The 
 ureteric orifice varies in appearance. Normally, it is seen 
 as a dimple, pit, or a fine slit, sometimes as a truncated 
 cone with gently sloping sides. The mucosa around the 
 ureters is more pink in colour than elsewhere. In inflam- 
 matory conditions the ureteric openings appear as round 
 holes in cushioned prominences, or "as a f\ with the 
 point directed outwards." Often, the fluid may be seen 
 to escape from the ureters in little jets. 
 
 In connection with this method the ureters themselves 
 may be examined. They may be sounded by means of a 
 
i86 
 
 CASE-TAKING. 
 
 Fig. 52. — Kelly's 
 speculum, with 
 obturator. 
 
 long, delicate instrument, the searcher, and they may 
 be catheterised. This method of removing urine from 
 the ureters is valuable in relation to the comparison of 
 
 the kidneys in disease. The 
 catheter is left in the ureter 
 for a few minutes, or for an 
 hour or more, and the urine 
 collected. The other ureter 
 is during this time discharg- 
 ing into the bladder, and its 
 urine can be drawn off with 
 an ordinary catheter. 
 
 The specula numbered from 
 8 to 1 6 will satisfy the re- 
 quirements for most ordinary 
 cases. No. lo or No. 12 
 will suffice for inspecting the 
 bladder, and for passing a catheter into the 
 ureter. These numbers can be used with- 
 out anoesthesia. If No. 14 or a larger size 
 be used an anaesthetic will generally be neces- 
 sary. 
 
 The genu-pectoral position may also be used 
 for examination with these instrumenfa. This 
 is necessary in inflammatory cases with thick- 
 ened walls, where ballooning of the bladder 
 will not occur when the patient is placed in 
 the other position. The ureters are not so 
 easily seen in this fashion. They are concealed 
 by the outer ends of the fold due to the inter- 
 ureteric ligament. Sometimes a satisfactory 
 examination may be made when Sims' position 
 is used, the pelvis being elevated. v 
 
 (e) The bladder may also be examined with a metal sound 
 in cases in which stone is suspected, or small phosphatic 
 deposits on the bladder wall. Stones of any size but the 
 
 i \ 
 
Esa 
 
 PHYSICAL EXAMINATION. 
 
 187 
 
 very smallest should be made out on bimanual examina- 
 tion. 
 
 (/) Sometimes the base of the bladder may be opened 
 into by a mesial cut through the interior vaginal wall 
 in order that the vesical mucosa may be examined. Such 
 a method is only employed where it is thought that some 
 operative treatment may follow, e.g. the removal of a 
 tumour, or where it may be necessary to drain the bladder 
 by the vaginal opening. 
 
 ((,>■) Electric cystoscope. — Leiter's instrument is a metal 
 catheter, ending in a beak bent at an angle {catheter coude). 
 On the concave or anterior surface of the beak is a rock- 
 crystal window. Within ^he catheter opposite the window 
 is a small electric lamp. Close to the bend another 
 window is placed on the anterior surface of the long part 
 of the catheter. Inside the tube opposite this window is a 
 prism, by means of which the rays of light are transmitted 
 along the catheter to the observer's eye. 
 
 In the outer part of the instrument an arrangement 
 of lenses causes a magnification of the field of view. The 
 catheter above described is used for the examination of all 
 the surface of the bladder save the base. For the latter a 
 tube must be used with a window on the posterior surface 
 of the beak. 
 
 Use of the instrument. — The urethra must be able to 
 admit the catheter (No. 22 French). The bladder must 
 be able to hold from 2 to 4 oz. of fluid. If the 
 bladder be too sensitive to fill with the fluid, the pre- 
 liminary injection of cocain may be carried out. Rarely 
 is general anaesthesia necessary. If the urine be not clear, 
 the bladder should be washed out first. The fluid used 
 may be weak carbolic or ordinary salt solution. If more 
 than 4 oz. of fluid be injected, the bladder is dis- 
 tended too much to allow of proper inspection of the 
 walls. 
 
 Before the instrument is passed, it should be held under 
 
v.. 
 
 1 88 
 
 CASE-TAKING. 
 
 water to see that it works properly, 
 with glycerin. 
 
 It should be lubricated 
 
 Vaginal Specula. 
 
 As has already been pointed out, we have a means of 
 examining the walls of the vagina and the vaginal portion of 
 the cervix without the aid of instruments. If a woman be 
 placed in the genu-pectoral position, or in the lithotomy 
 posture with her pelvis elevated, and if the introitus vaginae 
 be then opened with the fingers, the air balloons the vagina, 
 and by means of a good light we can inspect the cavity thus 
 formed. Had the physics of the abdomen and pelvis been 
 known centuries ago, the history of the speculum would 
 have been different from what it is. Moreo^ •, had the 
 normal condition of the vagina been known long ago, there 
 would not have been so many imperfect instruments made. 
 It is only recently that the vagina was found out to be a 
 mere slit in the pelvic floor, and not the large cavity figured 
 in the old books. The exact length of the vagina, also, has 
 only been rightly known for a fcM years. For centuries it 
 was described as being several inches longer than it really 
 is, and the instruments were made accordingly. 
 
 The history of the speculum is interesting, but a detailed 
 account scarcely falls within the limits of a practical work. 
 The instrument was used among the Greeks and Romans 
 by Hippocrates, Soranus, Paulus, and others. Specimens 
 may be seen in Pompeii. 
 
 In later times it was employed by Ambrose Pare, Para- 
 celsus, and many others. All the ancient forms were 
 valvular or tubular, the latter being either funnel-shaped or 
 cylindrical. The oldest forms were valvular ; they possessed 
 two, three, or more blades. For a considerable period 
 before the time of R(?camier, the speculum had largely 
 fallen into disuse. This distinguished Frenchman reintro- 
 duced the instrument as an aid in diagnosis. His speculum 
 was funnel-shaped, 7 in. in length, and made of tin. It 
 
 ■ W 
 
VAGINAL SPECULA. 
 
 189 
 
 is to Marion Sims that we arc indebted for the spatular 
 form of speculum, which was introduced by him as a means 
 merely of opening the introitus vaginae while the patient 
 was in the genu-pectoral position, in order that the air might 
 rush in between the vaginal walls and distend them. Most 
 text-books, at the present time, describe the three chief 
 varieties of speculum, namely, tubular, valvular, and 
 spatular, giving ecjual prominence to each. For practice' 
 purposes all, except the spatular variety, may be abolished. 
 
 Spatular speculum. — The classical instrument is that of 
 Marion Sims. It consists of a handle with a duck-bill 
 blade at each end at right angles to the handle. The 
 blades are of unequal size. It is really a double speculum, 
 and is made of polished metal. In Bozeman's modification 
 of this instrument, the blades join the handle at a some- 
 what acute angle. 
 
 Though at first Sims got the idea of this instrument 
 while examining a patient in the genu-pectoral position, he 
 afterwards used the instrument to the same advantage when 
 the patient was placed in the modified genu-pectoral, or, as 
 it is generally called, the Sims' position. For many years 
 the speculum has been used in connection with this posture, 
 both for diagnosis and treatment. 
 
 Use of the Sims' speculum. — (a) In the Sims' position. 
 The patient is placed semiprone. She lies on her left side 
 on a couch or table, her left arm hanging over the edge next 
 the physician ; she then turns the upper part of the body so 
 that the breasts touch the table ; her knees are drawn up 
 and the right one made to touch the table with its inner 
 surface. It is evident that the transverse diameter of the 
 pelvis is oblique to the table, and that the pelvis is on a 
 higher level than the upper part of the abdomen. 
 
 The speculum is now introduced. The blade to be used 
 is warmed and oiled on its convex surface. Hold it by the 
 other blade in the left hand. Pass two fingers r ' the right 
 hand into the vagina to open it. Introduc e the blade 
 
 
 3 
 
190 
 
 CASE-TAKING. 
 
 \\ 
 
 4, 
 
 
 \ ■ 
 s 
 
 between them and push it upwards and backwards towards 
 the hollow of the sacrum, until the end lies in the posterior 
 fornix, the fingers of the right hand being withdrawn. The 
 perineum is now drawn well back, and the upper end of the 
 blade can be manipulated so as to move the cervix back- 
 wards or forwards. The 
 opening of the vagina has 
 led to the inrush of air, 
 ballooning occurs, and the 
 cavity can be examined 
 with a good light. To hold 
 the instrument steady, the 
 left hand should be placed 
 under the handle, its ulnar 
 surface resting on the right 
 buttock, the handle being 
 held between the thumb 
 and forefinger. By keeping 
 the outer blade on a higher 
 level than the inner, the 
 right labium can be kept 
 up somewhat, so that the 
 entrance to the vagina is 
 made more open. 
 
 The inner surface of the 
 labia — the surface of the 
 vagina except the posterior 
 part — and the vaginal por- 
 tion of the cervix, can now be examined. If necessary, 
 for better admission of light, the labia may be held aside, 
 or a retractor used to pull forward the tissues of the pubic 
 segment. 
 
 In this position, by shortening the length of blade in the 
 vagina, the uterus may be pulled down by means of a vol- 
 sella. A sound m'y be passed into the uterine cavity, 
 applications made to it, to the cervix, or to the vaginal wall. 
 
 Fig. 53. — Sims' speculum. 
 
 .i 
 
VAGINAL SPECULA. 
 
 191 
 
 Until recently this position has been largely employed for 
 the performance of several operations on the cervix, anterior 
 vaginal wall, and base of bladder. It will, however, be 
 found that it is most convenient to do almost all of these 
 operations in the lithotomy position. The Sims' position 
 is, therefore, becoming much less frequently employed. 
 
 {b) In the lithotomy position. The Sims' specimen may 
 be used in this position, but, of course, only as a spatula, 
 not in the same relationship as that which exists in the 
 genu-pectoral or modified genu-pectoral. It may be used 
 advantageously in the lithotomy position, but far more con- 
 venient for most purposes is the spatular speculum of 
 Simon. 
 
 Sitnofi's set of spatular specula. — By far the most con- 
 venient series of specula, both for examination and opera- 
 tion purposes, is some such form as that devised by Simon. 
 It consists of two handles, into which may be fitted a set of 
 spatular blades varying in length and width. Some of these 
 are concave, others are almost flat. One handle is used for 
 the posterior wall, the other can be used with a retractor- 
 like blade for the anterior wall. The blades are arranged to 
 suit vaginte of different sizes. In operative procedures the 
 greatest advantage can be obtained with little trouble. For 
 operations in which we want the introitus kept as wide as 
 possible, and the uterus pulled well down, — e.g. in amputa- 
 tion of the cervix, — the short broad blade which fits the 
 handle at an acute angle is most advantageous ; a long 
 narrow blade in such a case being most unsuitable. Blades 
 may also be obtained with wide lateral flanges which pro- 
 tect the labia. A hollow anterior blade is used by some in 
 operations for the purpose of irrigating the parts with an 
 antiseptic lotion, a rubber tube from the reservoir being 
 fastened to a tap on the blade. 
 
 The Simon instrument is meant to be used in the 
 lithotomy position, and it is evident that besides its great 
 value in operative work, it is most valuable in examination. 
 
 
 
 I 
 
V 
 
 I... 
 
 192 
 
 CASE-TAKING. 
 
 The combined use of two blades enables the physician to 
 inspect the vaginal portion of the cervix and the vaginal 
 walls. In operating, it is sometimes helpful to use retractors 
 as well, for the purpose of drawing the labia farther apart. 
 Ordinary copper retractors suffice for this purpose. 
 
 It is also evident that a handle, with one of the concave 
 
 blades, may be used in place 
 of a Sims' speculum if it be 
 desirable to examine a woman 
 in the genu-pectoral or modi- 
 fied genu-pectoral position. 
 If one be in possession of 
 a set of Simon's specula, it 
 is not necessary to have a 
 special Sims' or a tubular 
 speculum. 
 
 Some of the procedures for 
 which this instrument may be 
 used, besides its use in exam- 
 ination, are the following : — 
 Packing the vagina, making 
 applications to the endome- 
 trium, to the cervix, and to 
 the vaginal walls ; operations 
 on the vaginal walls, on the 
 base of the bladder, on the 
 cervix; curetting, removal of 
 polypi, ligature of uterine 
 arteries, extirpation of the uterus, colpotomy. 
 
 Tubular speculum. — This is made of various materials, 
 e.^. celluloid, metal, wood, glass, vulcanite. The one 
 most commonly employed is the Ferguson speculum. It 
 is a cylindrical tube with one end trumpet-shaped and the 
 other bevelled. Owing to the bevelling, one side is longer 
 than the other, so as to suit the vaginal walls. Several sizes 
 of this instrument are used. 
 
 Fig. 54.- 
 
 -Simon's set of spatular 
 specula. 
 
VAGINAL SPECULA, 
 
 193 
 
 This speculum is passed ordinarily when the patient lies 
 in the lateral position, but it may be used in the lithotomy. 
 When it is introduced the cervix should be in the upper 
 end. 
 
 Such a speculum is of very little use. Through it the 
 vaginal portion of the cervix only can be seen. No opera- 
 tions can be performed with it save pricking Nabothian 
 follicles. Practically, it is only good for making applications 
 to the vaginal portion of the cervix, and 
 to the lower portion of the cervical canal 
 in certain cases. A sound cannot be 
 passed into the uterine cavity through 
 this speculum without difficulty, and, in- 
 deed, it should not be attempted. 
 
 I have also used it to advantage in 
 making applications to the vaginal walls, 
 in the following manner : — The speculum 
 is introduced. Through it a pledget of 
 wool, soaked in the fluid to be applied, 
 is passed up to the cervix by means of 
 a pair of long forceps. The speculum 
 is now gradually withdrawn, the pledget 
 following it. In this way the vaginal 
 walls close on the wool from above fig. 55.— Fergusson's 
 downwards, and so get touched by the speculuju. 
 
 medicinal fluid. 
 
 Unless care be taken, the tubular speculum may 
 give a wrong impression as to the condition of the 
 cervix. When it is in position it may bring the flaps 
 of a split cervix together so as to hide the lesion. 
 The ordinary long instrument, by being puslied well 
 up into the fornix, may give a false impression as to the 
 length of the cervix; it may cause it to be apparently 
 elongated. 
 
 Valvular speculmn. — Of this form there are many 
 varieties. Perhaps the best known is Cusco's bivalve 
 13 
 
 •^rffmmw^ I If w» !■ 
 
I 
 
 194 
 
 CASE-TAKING. 
 
 speculum. Neugebauer's and Barnes' instruments are also 
 described in the books. 
 
 The Cusco speculum is introduced into the vagina with 
 the blades closed. In position, they should lie against the 
 anterior and posterior walls. By means of the attachments 
 at the outer ends of the handles the inner ends of the 
 blades can be separated. 
 
 The Neugebauer and Barnes instruments are introduced 
 in the same manner. The posterior blade is passed, and 
 then the anterior, the latter sliding along the former. 
 
 These valvular specula are of no greater value than the 
 
 tubular forms. In- 
 deed, the gyne- 
 cological specialist 
 never uses them. 
 The cervix may 
 be examined by 
 means of them, 
 but they are of no 
 use for operative 
 procedures. It is 
 important to note 
 that they may 
 give an entirely erroneous impression of the cervix in 
 certain states, e.g. if a cervix be lacerated, the valvular 
 speculum when opened, by separating the flaps and caus- 
 ing the red mucosa of the canal to appear, may lead 
 the physician to think that marked endocervicitis, with 
 the formation of a catarrhal patch, exists. In the olden 
 days it would probably have been diagnosed as an 
 ulceration. 
 
 Finally, in all cases, before a speculum be used, the 
 bimanual examination should be made. For mere pur- 
 poses of diagnosis, owing to the importance of this latter 
 method, the gynecologist rarely nowadays requires to use 
 any speculum. It is only in certain cases that it is of 
 
 Fig. 56. — Cusco's speculum. 
 
 I \ 
 
THE VOLSELLA. 
 
 195 
 
 benefit. Its great value is in operative procedures. As an 
 aid in diagnosis it is generally found that the instrument is 
 most used by the practitioner who has had little experience 
 in the special diseases of women. 
 
 The Volsella. 
 
 This instrument is used for grasping tissues during opera- 
 tions, or in examinations. It is simply a pair of forceps. 
 For holding the cervix an instrument 8 or 9 in. in 
 length may be used. It may be straight or curved ; the 
 latter form is more easily kept out of the way of the 
 physician when the anterior lip of the cervix is held during 
 an operation. The blades should have a separable joint, as 
 indeed should all forceps, in order that the instrument may 
 be kept easily aseptic. Near the handle there should be a 
 catch by which the blades can be held together when they 
 are closed. The simplest and best form is that which is 
 found on the well-known Pean artery forceps ; it can be 
 opened and closed without the use of two hands. The 
 grasping teeth at the ends of the blades are two, three, or 
 four in number, and vary in size. This instrument may be 
 used, also, to hold tumours, to grasp the vaginal walls or 
 external genitals in operative procedures. For most vaginal 
 and perineal operations, however, artery forceps may be used 
 to hold up the tissues. The most suitable form is that 
 devised by Kocher ; at its end is a sharp tooth by which 
 the tissues are firmly held. 
 
 Ordinary bullet-forceps can also be used for the same 
 purposes. 
 
 A special uterine volsella may also be used for certain 
 cases of vaginal extirpation of the uterus or for colpotomy. 
 One blade longer than the other ends like a uterine sound ; 
 it is meant to be passed into the uterus. The other blade 
 is like that of an ordinary volsella, and fastens into the 
 outer surface of the cervix. This instrument gives a firm 
 
 'mummmmmt^ 
 
196 
 
 CASE-TAKING. 
 
 grip of the uterus, and the inner blade keeps it stiff, so 
 
 that it can be better palpated and manipulated during 
 
 the operation. 
 
 With the volsella the uterus, in normal conditions, can 
 
 be pulled downwards almost as far 
 as the introitus vaginae. In many 
 pathological conditions — e.g. cel- 
 lulitis and peritonitis — this is im- 
 possible. As it is pulled down it 
 tends to become straightened and 
 to lie in the long axis of the 
 vagina. The vaginal walls become 
 inverted, and the bladder and am- 
 pulla of the rectum somewhat 
 drawn down. 
 
 The cervix may be seized by 
 the volsella without or with the 
 use of the speculum. Generally 
 the anterior lip is caught, but the 
 other may be held if it be neces- 
 sary. 
 
 {a) Without the use of the specu- 
 lum, — The patient may lie in the 
 lateral or lithotomy position. The 
 two first fingers of the right hand 
 are passed until the cervix be 
 touched. The volsella, held by the 
 left hand, is passed along these 
 fingers and the anterior lip grasped 
 and pulled down. 
 
 {!)) With the speculum. — When 
 the vagina is opened either in 
 the Sims', the genu - pectoral,. 
 
 or the lithotomy posture, it is a simple matter to pass 
 
 the speculum and grasp the cervix. 
 
 The following are the uses of the speculum : — 
 
 Fig. 57.— Volsella. 
 
 \\ 
 
THE VOLSELLA. 
 
 197 
 
 {a) In diagnosing the extent of a cervical laceration, and 
 judging the presence or extent of a catarrhal patch. Each 
 flap is grasped with a volsella, and they are approximated 
 and separated. If, when the lips are brought together, the 
 red patch does not disappear, an endocervicitis 
 is present, and is extending downwards on to 
 the vaginal portion of the cervix. 
 
 {b) In diagnosing the relation of the uterus 
 to large tumours which occupy the abdominal 
 cavity. An assistant holds the tumour, and 
 the physician pulls on the cervix by means 
 of a volsella, or the latter may merely steady 
 the instrument while the assistant pulls upward 
 on the tumour. If the tumour be adherent 
 to the uterus, or grow from it, they will move 
 together during the examination, save when the 
 adhesions are very long, or the tumour has a long 
 pedicle. Of course, where the tumour or the 
 uterus be fixed to other structures, their move- 
 ments may be interfered with, and we may gain 
 little information from the use of the volsella. 
 
 {c) In performing the rectal examination, we 
 may often be greatly helped by drawing down 
 the cervix with a volsella. The examining finger 
 can more readily palpate — uterus, tubes, ovaries, 
 and broad ligaments. 
 
 {d) The chief use of the instrument is in 
 operations on the genital tract, wherever it is 
 desired to hold a piece of tissue steadily or to Fig. 58. — A 
 make traction on it, e.g. in curetting, amputa- P-'i" ofbullet- 
 tion of the cervix, etc. 
 
 The volsella should not be used to pull down the cervix 
 in acute peritonitis or cellulitis, in pyo-, haemato-, or hydro- 
 salpinx, in tubal gestation, in haematocele or hematoma, or 
 in advanced cancer of the cervix. 
 
 A simple tenaculum is recommended by some for the 
 
 i J .'■ 
 
 W 
 
■98 
 
 CASE-TAKING. 
 
 purpose of steadying the cervix. It is not so serviceable as 
 a volsella. Such an instrument is practically only of service 
 in vesico-vaginal fistula operations. 
 
 The Uterine Sound. 
 
 In ancient times a sound was used in examining the 
 genital tract, but it is highly probable that it was limited 
 to the vagina. Mention is made of the instrument by 
 Paulus i4i!gineta and Soranus. For a long time its use 
 was forgotten, until it was reintroduced by Levret. It 
 is, however, to Sir James Y. Simpson that we owe the 
 wide use to which the sound has been put in gyne- 
 cological practice during the last fifty years, though there 
 is no doubt that the instrument has been far too extensively 
 used. In the pre-antiseptic days it was often a source of 
 infection. But its employment in diagnosis has, during 
 recent years, been very largely diminished, as a result of 
 the perfected methods of examining patients by the hands 
 alone. In the consulting-room the sound need be used but 
 rarely. 
 
 Many sounds have been made by gynecologists, but only 
 one or two need be described. Any flexible metal rod, with 
 a knob-pointed end, will serve as a sound. One of the best 
 known and most serviceable is Sir J. Y. Simpson's sound. 
 A. R. Simpson's sound is a modification of it, and was 
 introduced for a special purpose. Sir J. Y. Simpson's sound 
 is about 12 in. long, and made of nickel-plated copper. 
 It can be moulded to any desired shape, yet it is not too 
 soft. The handle has a rough and a smooth surface, the 
 rough being on the side towards which the point of the 
 sound looks. When the sound is /// utero, we thus always 
 know the direction of the point. 
 
 The end of the sound is rounded and blunt. Two and 
 a half inches from the end is a round knob, and at every 
 inch beyond this there is a mark. On the old forms of this 
 
THE 'UTERINE SOUND. 
 
 199 
 
 sound there was a notch i \ in. from the point ; this is a 
 source of weakness, and is unnecessary. 
 
 Points to be observed before passing the sound. — It 
 
 should not be passed during menstruation, nor during an 
 acute attack of inflammation in the peritoneum, cellular 
 tissue, or internal genitals, nor in a case of uterine cancer, 
 except when there is some special reason for its use. 
 Above all, care should be taken that the woman is not 
 pregnant. If she has missed a period, the sound should 
 not be passed unless it be certain that there is no ovum 
 in the uterus. 
 
 A careful bimanual examination should always be made 
 before the sound is used. The physician should gain a 
 good idea as to the position and shape of the uterus, and 
 should curve the instrument accordingly. 
 
 Method of using the sound.— The sound may be passed 
 when the patient is in the Sims', in the lateral, or in the 
 lithotomy position. If she be in the Sims' posture, the cervix 
 should be pulled down with a volsella before the instrument 
 is introduced. 
 
 The lithotomy position may be used if the patient be 
 anaesthetised. In ordinary practice the left lateral position 
 is satisfactory. 
 
 After the bimanual has been performed, the patient turns 
 on her left side, and draws up her knees. The sound is 
 rendered thoroughly aseptic, and its point is dipped in 
 antiseptic vaseline. The first cwo fingers (or the index only) 
 of the right hand are introduced into the vagina so that 
 the tips touch the cervix, the palmar surface being turned 
 towards the sacrum. The left hand holds the handle of the 
 sound lightly, so that its rough surface is directed towards 
 the back, and guides the point along the palmar aspect of 
 the vaginal fingers until it enters the os uteri. 
 
 In cases ivhere the litems lies to the fronts the end of the 
 sound is gently directed into the cervical canal for about half 
 an inch. The handle of the instrument is next carried by a 
 
 
 |i 
 
 <'')| 
 
 ii 
 
2CX} 
 
 CASE-TAKING. 
 
 \ I 
 
 i 
 
 
 ri !■ 
 
 long sweep until it lies under the symphysis, its rough side 
 directed towards the front. The handle is next simply 
 moved backwards towards the perineum. By the latter 
 manceuvre the point of the sound moves forward to the 
 fundus of the uterus. 
 
 If the uterus be retroverted the method is simpler. No 
 long rotation of the handle is necessary. After the point of 
 the sound has entered the cervical canal, the handle of the 
 sound is moved directly forwards towards the symphysis. 
 In this way the point of the instrument moves backwards 
 to the fundus uteri. 
 
 When the patient is in the lithotomy position, the sound is 
 passed directly, being held according to the position of the 
 uterus. Thus, if the uterus lie to the front, the handle is 
 held at first in the middle line opposite the symphysis, and 
 then moved backwards ; at the same time the point of the 
 sound moves directly to the fundus. 
 
 In all cases no force is to be used ; the sound should 
 merely glide into the uterus. In normal cases no pain 
 should be caused, though often the patient has an un- 
 pleasant feeling. In nervous women, or in cases in which 
 the canal is very narrow, there may be a feeling of colic or 
 of sickness. No bleeding should be caused by the passage 
 in normal conditions. 
 
 Difficulties in passing the sound. — The point may catch 
 in a fold of the arbor vitse of the cervical mucosa. It 
 should not be forced through the obstruction, but should 
 be withdrawn somewhat, and passed along again until it 
 slides by the fold. Owing to marked displacement of the 
 uterus, it may be impossible to get the sound into the os ; 
 in such a case it may be necessary to pull down the cervix 
 with a volsella. In cases of marked anteflexion or retro- 
 flexion it may be impossible to pass the sound round the 
 bend ; by pulling down the cervix or pushing up the fundus 
 with the vaginal fingers (or with a finger in the rectum if 
 the uterus be retroflexed), the difficulty may be overcome. 
 
 \' 
 
 I \ 
 
 t. . 
 
THE UTERINE SOUND. 
 
 20 1 
 
 If there be stenosis, either of the external or of the internal 
 OS, it may not be possible to pass the instrument. If the 
 uterine cavity be tortuous, owing to the bulging of a tumour 
 in its wall or to the presence of polypi, it may be impossible 
 to guide the sound through the whole length of the canal. 
 For these last-mentioned cases a soft bougie or catheter is 
 recommended by some ; one may be deceived in their use, 
 however, because they may curl up in the cavity, and give 
 one a false idea as to the length of the canal. When there 
 is atresia of the uterine cavity, of course the sound cannot 
 be passed. There are different conditions in the vagina 
 also which make it impossible to sound the uterus, e.g. 
 narrowing, the presence of large polypi in it, etc. 
 
 Use of the sound. — {a) In diagnosis, — i. To ascertain 
 the length of the uterine cavity. In ordinary practice this 
 is the chief use to which the sound is put. 
 
 2. To determine the thickness of the walls of the uterus. 
 This rarely is done. For the posterior wall, a finger is 
 introduced into the rectum ; for the anterior, it is passed 
 into the anterior fornix, into the bladder or against the 
 abdominal wall. 
 
 3. To estimate the degree of patency of the uterine canal, 
 This has special reference to the cervical portion. In the 
 great majority of cases it is only the os externum or the 
 OS internum to which attention is paid. Atresia or stenosis 
 may be diagnosed. 
 
 4. To ascertain the presence of tenderness in the walls 
 of the uterus, and to detect irregularities or tumours of the 
 inner surface. In several diseased conditions bleeding may 
 be caused. 
 
 5. To determine the direction of the uterine axis, and the 
 relation of the body to the cervix, in cases where this is 
 impossible by means of the bimanual examination. In the 
 great majority of cases the bimanual alone is sufficient for 
 the determination of the position and flexion of the uterus. 
 But in certain cases — e.g. in tumours of the uterine wall. 
 
 m 
 
 A It 
 
202 
 
 CASE-TAKING. 
 
 I 
 
 in large, bloody, or inflammatory exudations around the 
 uterus ; in cases of small exudations, cellulitic, or peritonitic ; 
 in irregular or multiple tumours of various kinds in close 
 relationship to the uterus — the bimanual may not be able to 
 distinguish the fundus uteri. 
 
 The sound must be passed most carefully. While it is in 
 position, the bimanual is performed, the instrument being 
 held by the vaginal hand. The abdominal hand may feel 
 the fundus uteri pushed upwards by the end of the sound. 
 It is for such an examination that the A. R. Simpson sound 
 is more useful than the Sir J. Y. Simpson instrument. 
 Owing to the length of the latter it is not easily held by 
 the vaginal hand. The shorter A. R. Simpson sound when 
 passed rests by its handle on the hand, where it is held by 
 the ring and little fingers against the hypothenar eminence. 
 
 In cases of flaccid uterus it is valuable to do the bimanual 
 while the sound is in utero. 
 
 6. To determine the mobility of the uterus in certain 
 cases. The sound is rarely required for this purpose. 
 When it is desired to make out the relation of a large 
 tumour to the uterus, the sound may be passed and its 
 movements noted while the tumour is moved by the other 
 hand, or by an assistant. It is never justifiable to attempt 
 to move the uterus in order to determine the effect on the 
 tumour. Nor is it right, in a case where there is no tumour, 
 to move the uterus about by means of the sound. Mobility 
 of the uterus should be determined by the bimanual 
 examination. 
 
 {h) In treatment. — i. To replace a retroverted or retro- 
 flexed uterus i^ide p. 458). 
 
 2. To dilate a stenosed uterine canal. For this purpose 
 it is generally used along with special dilators. 
 
 3. To apply fluids to the uterine mucosa ; for this pur- 
 pose its end is covered with wool {vide p. 223). 
 
 Dangers in the use of the sound. — The great danger is 
 that connected with the introduction of septic organisms, 
 
 '\ 
 
DILATORS. 
 
 203 
 
 as a result of which general blood poisoning may follow, or 
 local pelvic inflammation of various forms. The uterine 
 wall may be perforated when it is thin, as in superinvolution ; 
 or when it is soft, as after an abortion. Cases have, however, 
 been described where this accident has been unattended 
 with serious results. Severe haemorrhage may be caused 
 sometimes, e.g. when the mucosa is in a condition of 
 haemorrhagic endometritis, or in new-growth formation in 
 the mucosa. Another great risk is the passage of the sound 
 in cases where the physician has failed to exclude the 
 existence of pregnancy. The greatest caution should be 
 exercised. 
 
 Dilators. 
 
 Dilatation of the genital tract. — Dilatation is employed 
 both for purposes of examination and of treatment. 
 
 {a) Vagina. — For purposes of examination it may some- 
 times be necessary to dilate the intrortus or the canal itself. 
 The following means are used : — 
 
 1. The continued plugging of the vagina. 
 
 2. Gradual uuatation with Barnes' bags. 
 
 3. The introduction of different sizes of hard rubber or 
 glass tubes. 
 
 4. The insertion of round or oval dilators, e.g. Boze- 
 man's. 
 
 The dilatation may be continued for one, two, or more 
 days, according to the nature of the case, and the examina- 
 tion should be made as soon as the dilatation is completed. 
 
 In the treatment of such conditions as stenosis of the 
 vagina, or atresia which has been opened, or in cases where 
 more room is needed for operations on the vaginal walls, 
 base of bladder or uterus, the canal may be dilated by one 
 or other of these methods. In addition, however, the two 
 following plans must be kept in mind : — 
 
 5. Dilatation with the hand under chloroform, the fingers 
 being arranged as a cone. This method is used in certain 
 
 ■m 
 
 H! m 
 
 . „.-.-..x -<t'. 
 
■ 
 
 ao4 
 
 CASE-TAKING. 
 
 
 1 1 :' 
 
 forms of dyspareunia, and to gain more room in operations 
 on the upper genital tract. 
 
 6. Incision of the perineum. This may sometimes be 
 necessary in operations, e.g. the removal of an intra- 
 
 FiG. 59. — Hegar's dilators. 
 
 Uterine polypus in a nullipara. The incision f^aould be 
 made on each side, a short distance from the middle of the 
 anterior margin of the perineum. The cut should extend as 
 deeply as is necessary in a backward and outward direction. 
 Bleeding points must be tied, and antiseptic precautions 
 
 \ \ 
 
DILATORS. 
 
 205 
 
 observed. At the end of the operation the wounds are 
 closed with catgut suture. 
 
 (b) Uterine canal. — The uterine canal may require to be 
 dilated both for purposes of diagnosis and of treatment, 
 e.g. where a polypus, malignant disease, or remains of 
 placenta and membranes may be suspected to exist in the 
 uterine cavity, in stenosis of the canal, to allow passage of 
 a curette, or application of medicaments to the mucosa, etc. 
 The following methods may be employed : — 
 I. By the use of a series of graduated dilators. — Hegar's 
 instruments are very suitable. In a complete set there are 
 thirty, measuring in diameter from yV to lyV in. Their 
 length should be 6 or 7 in. They are made of vulcanite 
 
 
 Fig. 60. — Hank's dilators. 
 
 or metal. The smallest sizes are apt to break when 
 made of the former material. Hank's dilators are also 
 serviceable. 
 
 Method of use. -—It is generally most convenient to anaes- 
 thetise the patient, who is placed in the lithotomy position. 
 The vagina is made thoroughly aseptic. T'he dilatation is 
 carried out with thorough antiseptic precautions. The 
 position and relations are made out by means of the bi- 
 manual. The cervix is drawn down and held steady by 
 means of a volsella or two. The size and direction of the 
 canal is estimated with a sound, and the dilators, dipped 
 in antiseptic oil or vaseline, are passed in succession until 
 the necessary degree of dilatation is reached. 
 
1 
 
 m 
 
 u 
 
 206 
 
 CASE-TAKING. 
 
 There may be difficulty owing to a marked flexion 
 of the uterus. In such a case a finger placed in the 
 anterior or posterior fornix, or in the rectum, may help 
 to straighten the uterus while the dilators are being passed ; 
 or special metallic curved bougies may be used. In ex- 
 treme rigidity of the wall there may be 
 difficulty in introducing the dilators. In 
 such a case it is often advisable to use a 
 metal instrument, like that of Sims or 
 Ellinger, along with the Hegar dilators. 
 
 In very many cases the wall of the 
 uterus is not torn when dilatation is com- 
 plete, but sometimes it is, especially at the 
 internal or external os. 
 
 After dilatation is completed, and the 
 examination finished, the canal is washed 
 out with an antiseptic. If an operation be 
 performed, various procedures may be 
 adopted {;vide Various Operations). 
 
 In certain conditions of the uterus the 
 finger may be introduced into the uterus 
 without preliminary dilatation, namely, 
 after an abortion or full-time labour ; or 
 after a polypus has passed through the 
 cervical canal. 
 
 2. By the use of steel dilators with 
 separable blades. — Sims' and Ellinger's 
 instruments are very serviceable if made 
 Fig. 61.— Ellinger's of good metal. The former has three 
 dilator. blades, the latter two. 
 
 Method of use. — Patient is arranged as before described- 
 The dilator is passed, with closed blades, through the 
 cervical canal, and then either the screw at the end of the 
 handles is turned, whereby the blades separate slowly and 
 dilate the cervix, or the hands may press the handles 
 together, whereby more forcible dilatation is caused. If 
 
 ' \ 
 
DILA TORS. 
 
 207 
 
 the dilator will not enter the canal it is necessary to pass 
 several small Hegar bougies, in order to enlarge the passage 
 sufficiently. It is best not to attempt great dilatation with 
 this instrument. It should only be 
 used for moderate degrees. 
 
 3. Enlargement of the cervical canal 
 may sometimes require to be brought 
 about by means of cutting operations. 
 (These will be described later, vide 
 
 P- 435-) 
 
 4. By the use of tents. — Formerly 
 
 tents were largely employed in gyneco- 
 logical practice. Now they are but 
 rarely required. Three varieties are 
 employed, namely, sponge, tangle, and 
 tupelo tents. 
 
 Sponge-tent. — The sponge-tent is an 
 elongated cone-shaped piece of dried, 
 compressed sponge, impregnated with 
 an antiseptic. When introduced into 
 the uterus it stimulates the mucosa to 
 secrete, and the fluid soaking into the 
 sponge causes it to expand, and so to 
 dilate the canal. Before it is used it 
 may be immersed in a concentrated 
 alcoholic solution of carbolic acid, or 
 in a saturated solution of iodoform in 
 ether, with a little alcohol. Then it 
 may be rapidly scrubbed in i in 500 
 corrosive solution. Each one is pro- 
 vided with a string by means of which 
 it may be pulled out of the cervix 
 after use. 
 
 Method of use. — The patient is placed in the lateral, in 
 the Sims', or in the lithotomy posture, and the genital 
 tract thoroughly cleansed with an antiseptic lotion. A 
 
 1- 
 
 Fig. 62. — Sims' 
 dilator. 
 
 
 A 
 
208 
 
 CASE-TAKING. 
 
 speculum can be used to expose the cervix, which is 
 pulled down with a volsella. The tent is then passed 
 into the cervical canal by means of the fingers or a pair 
 
 w 
 
 '^^-^A 
 
 I. 2. 3. 
 
 Fig. 63.— Tents. 
 I. Tangle ; 2. Tupelo ; 3. Sponge. 
 
 \ 
 
 of curved dressing forceps ; special tent-introducers are not 
 necessary. 
 
 In some cases no speculum need be used. In other 
 
 '\ 
 
TENTS. 
 
 209 
 
 cases where one lacks assistance, the tent may be introduced 
 while one hand steadies the fundus through the abdominal 
 wall. 
 
 When the tent is in position its base should remain 
 outside the os externum. It should be held in the 
 cervix for a little. If it shows no tendency to slip out, 
 no vaginal plug is necessary. If it tends to move, 
 an antiseptic tampon should be introduced. The tent 
 should not be left in the cervix longer than twelve hours. 
 During the process of dilatation an occasional anti- 
 septic douche should be given, and after dilatation the 
 douche should be repeated. If necessary another and a 
 larger tent can be introduced. The tent is removed by 
 gentle oscillatory traction on the string. Care should 
 be taken that no piece is torn off and left behind in the 
 uterus. 
 
 Tangle-tent, — This is made of the stem of the sea-tangle 
 {Laminaria digitatd). It may be solid or perforated. The 
 latter expands more rapidly than the solid form, but is 
 not so effective. This tent may be impregnated with 
 an antiseptic, because after soaking it will, if dried, get 
 smaller again, though it may somewhat lose its rounded 
 shape. It can, however, be smoothed off. Before its 
 introduction it can be softened in a hot antiseptic, and 
 bent to the curve of the uterine canal. If placed in 
 a cold lotion for a little it retains this form. If neces- 
 sary several small tents, bound together by a rubber 
 band, may be introduced into the cervix instead of 
 a single one. Tangle dilates least rapidly of the three 
 forms. 
 
 It is introduced in the manner described for the sponge- 
 tent. It tends to slip out unless kept in position by a 
 vaginal tampon. 
 
 Tupelo-tent. — This is made of the root of the Nyssa 
 aqiiatilis. It cannot be soaked with an antiseptic, because 
 if once expanded it will not return to its original size. It 
 14 
 
 I 
 
2IO 
 
 CASE-TAKING. 
 
 dilates rapidly when in position, but not to such a marked 
 degree as the sponge-tent. 
 
 Dangers connected with the use of tents. — All tents are 
 dangerous because of the risk of introducing septic material. 
 The most dangerous is the sponge-tent, because it tends 
 most of all to injure the mucous membrane, and to produce 
 a profuse secretion which may collect and decompose ; it is 
 difficult to cleanse it thoroughly ; a part of it may be torn 
 off and left in the uterus, when its removal is difficult owi ig 
 to the contraction of the uterus on it. Tangle and tupelo 
 tents are much safer. 
 
 Points to be observed with regard to their use. — If possible 
 pass the tent only once. Do not introduce more than two 
 in succession. The patient must remain in bed during 
 and after their use. They must be introduced under strict 
 antiseptic precautions. While in position the vagina should 
 be douched every three or four hours. Tents are not to 
 be used in acute inflammation in the pelvis, nor in blood 
 extravasations, nor in cancer of the cervix, nor where dis- 
 tended Fallopian tubes are present. 
 
 The Curette. 
 
 This instrument was first employed by R^camier in 1846. 
 It is used in scraping the endometrium for diagnostic pur- 
 poses {i.e. for the examination of the tissue removed), and 
 also for treatment. 
 
 Various forms of curette are in use. The following need 
 only be described : — Roux', Simon's, and R^camier's. 
 Roux' has an elongated hollowed-out portion, with sharp 
 edges at each end of a handle, one of which is larger 
 than the other ; it is made of steel. The ends should 
 be rounded, not pointed. This form is used by Martin 
 of Berlin. 
 
 Simon's curette has a round, spoon-shaped end, with 
 sharp edges. 
 
 
 l\ 
 
THE CURETTE. 
 
 211 
 
 R^camier's instrument has a loop end, one end of which 
 is sharpened. 
 
 Dull wire curettes have been used, but they are quite 
 unnecessary. Perforated spoon curettes are used by some ; 
 they allow a stream of antiseptic lotion to irrigate the 
 uterine cavity during the curetting. 
 
 Method of using the curette. — The patient, with empty 
 bladder and rectum, is placed in the lithotomy position 
 (some use the Sims' position). A careful bimanual is 
 performed. The vulva and vagina are thoroughly cleansed. 
 Anaesthesia is advisable, though without it the operation 
 may sometimes be performed without causing pain. 
 
 A short-bladed spatular speculum is introduced posteriorly, 
 and held by an assistant. The cervix is drawn down by a 
 volsella placed in the anterior lip ; the handle is held by 
 the assistant over the symphysis. A sound is next passed 
 to estimate the size and direction of the uterine cavity. If 
 the cervical canal is large enough to admit the curette quite 
 easily, no dilatation is necessary. If it be not, Hegar's 
 dilators or an expanding dilator may be used. The cavity 
 is next washed out by means of a double catheter. Then 
 the curette is introduced as far as the fundus. If the whole 
 endometrium is to be scraped, the operation should be done 
 in a systematic fashion, i.e. the anterior wall should first 
 be attended to, then the posterior, then the fundus, and, 
 finally, the lateral borders. 
 
 Unless such a methodical process be adopted, some parts 
 of the mucosa are apt to be left untouched. 
 
 In scraping, the forefinger of the left hand should be 
 placed in the fornices against the uterus, and it should 
 be moved about so that the instrument always works 
 against it. 
 
 When a scraping is to be made for examination, only 
 the part desired need be removed. If there be enc' :>- 
 cervicitis around the os externum, the diseased part may 
 also be scraped off. In many cases, as the curette touches 
 
 
 :.^ i 
 
212 
 
 CASE-TAKING. 
 
 \\ 
 
 Fig. 64. — Curettes. 
 
 1. Roux' (often named Marti.i's). 
 
 2. Simon's. 
 
 3. Loop of R^camier's. 
 
 ! \ 
 
THE CURETTE. 
 
 213 
 
 the muscular wall, a grating sound is made. The same 
 sound is produced if dense new growths are present ; also 
 when the curette scrapes the folds of the cervical mucosa in 
 certain cases of hyperplastic endocervicitis. 
 
 All debris is now washed out of the uterus and vagina 
 with a hot antiseptic lotion. Iodised phenol or some other 
 styptic is generally applied to the rawed surface, an anti- 
 septic tampon is placed in the vagina, and the patient is 
 put to bed. In cases where the uterus is soft or hsemor- 
 rhage is feared, an antiseptic tampon may be placed in the 
 uterus. 
 
 After-treatment. — The vaginal tampon is removed on the 
 day following the operation, and an antiseptic douche given. 
 This is continued twice a day for a week ; thereafter once 
 daily as long as may be required. The patient may get out 
 of bed at the end of eight or nine days, save after abortions, 
 and in cases where it may be necessary for other reasons 
 to keep her at rest. She must only gradually return to her 
 iuties. 
 
 Conditions in which the curette is employed, — In inflam- 
 matory conditions of the uterine mucosa ; in incom- 
 plete abortion ; in adenoma, sarcoma, and carcinoma of 
 the mucosa ; in conditions of the mucosa whose diagnosis 
 is uncertain. 
 
 In the great majority of cases Roux' curette will be 
 found to be the most serviceable. 
 
 In abortion cases, or in sarcoma or adenoma cases, where 
 large masses are to be removed quickly, a large Simon 
 curette is, perhaps, the most convenient. 
 
 Contra-indications and dangers. — Pregnancy, acute in- 
 flammatory conditions in the pelvis, distended Fallopian 
 tubes. Formerly chronic inflammation in the pelvis was 
 mentioned as a contra-indication, but this belief must be 
 abandoned. Curetting is not risky in these cases if thorough 
 antisepsis be carried out. Moreover, the curetting may 
 benefit the chronic condition by removing what is so often 
 
 ii 
 
 Hi! 
 
214 
 
 CASE-TAKING. 
 
 an area of germ infection, namely, the diseased mucosa of the 
 uterus. In regard to acute inflammations, it must be noted 
 that if they occur in the puerperium, they may be related 
 to diseased conditions in the interior of the uterus, and in 
 certain of these cases it is recognised that curetting is not 
 only justifiable, but absolutely necessary. 
 
 The dangers of curetting are the introduction of septic 
 infection, perforation of the uterus, causation of haemor- 
 rhage. 
 
 Antisepsis must be thoroughly carried out. The instru- 
 ment should be handled carefully. Perforation is most apt 
 to occur when the uterine wall is soft, as after an abortion, 
 or as a result of the infiltration of a rapidly growing sarcoma, 
 or when it is abnormally thin. 
 
 In the majority of cases there is little loss of blood 
 during or after curetting. It may be considerable, how- 
 ever, in haemorrhagic or fungous endometritis, in incom- 
 plete abortion, or in malignant disease. For such cases the 
 uterine tampon of iodoform gauze for a day or two is most 
 valuable. 
 
 ; , 
 
 The Aspirator. 
 
 In gynecological practice the aspirator is employed both 
 for purposes of diagnosis and of treatment. Its main use is 
 for the latter. 
 
 I. In the examination of women, in the majority of cases, 
 we are able as a result of the clinical history, and of careful 
 physical examination (especially under an anaesthetic), to 
 ascertain the presence of fluid, and to have a fairly correct 
 idea as to its nature. Still there are certain conditions in 
 which, owing to our uncertainty regarding these points, we 
 may desire to employ the aspiratory needle. 
 
 The swelling may be punctured through the vagina or 
 through the abdominal wall. The instrument must be used 
 under the most careful antiseptic precautions. In some 
 cases an ordinary hypodermic needle may suffice. In other 
 
 w 
 
■Jf 
 
 THE ASPIRATOR. 
 
 ?I5 
 
 cases a small aspirator with a long needle is required. The 
 larger aspirators used in treatment are not necessary for the 
 exploratory puncture. 
 
 2. Various forms of aspirator are used in treatment. 
 These will be described in connection with the operations 
 in which they are used. 
 
 ■I 
 
 .^^' 
 
 
 II 
 
 
 tl :iO 
 'I iN i 
 
CHAPTER VIII. 
 
 MINOR THERAPEUTIC MEASURES. 
 
 The Vaginal Douche. 
 
 This valuable therapeutic agency has been employed for 
 centuries. In the time of Hippocrates it was employed 
 merely to apply certain medicaments to the vaginal walls. 
 
 It was first employed for the purpose for which it is 
 mainly used nowadays in the fifteenth century. 
 
 Nature of apparatus. — The best form of douche apparatus 
 is one which allows of the flow of a continuous stream of 
 water, under the influence of gravity. The ordinary douche- 
 can, with rubber-tube attached, is the most convenient 
 instrument. According to the elevation of the can above 
 the patient, the force of the stream varies. The can may 
 be obtained in various sizes. The tube is furnished with 
 a stop-cock, and should have at its end a vaginal nozzle, 
 5 or 6 in. long, with lateral perforations near the distal 
 end. This nozzle may be straight or curved, and should 
 be made of vulcanite, though glass is largely employed. 
 Instead of the douche, a tube may be used with an ordinary 
 pitcher, the flow being obtained by syphon action. 
 
 A less convenient instrument is the largely used rubber- 
 syringe worked by means of a bulb. This allows only of an 
 intermittent stream, it is apt to fatigue the hand of the 
 person who works the bulb, and is liable to get out of 
 order. 
 
 Method of use. — The douche may be taken by the patient 
 
 !V 
 
THE VAGINAL DOUCHE. 
 
 217 
 
 herself, or may be given by a nurse or other person. The 
 most thorough method is to place the patient in the dorsal 
 position with a large bed-pan under her hips. The can, 
 filled with the necessary lotion, is placed at a suitable 
 distance above the patient, on a shelf, hung on a nail, 
 or held by someone ; the stream is started, and the nozzle, 
 thoroughly clean, is passed into the vagina as far as the 
 cervix ; the water which escapes from the vagina enters the 
 bed-pan. 
 
 If the patient has no assistance, it is usual for her to use 
 the douche sitting astride of a vessel. This position is 
 not so satisfactory, the fluid escaping too rapidly from the 
 vagina. 
 
 The lithotomy position is a convenient one, but is rarely 
 necessary. 
 
 When tile douche is used there must be room enough for 
 a good return outflow ; otherwise there is danger of fluid 
 being forced into the uterus and Fallopian tubes. Where 
 the vagina is not roomy, a large double catheter, like that 
 of Budin, may be used. 
 
 The patient should lie at rest for fifteen minutes or more 
 after the douche. 
 
 Indication for use. — To remove secretions from the 
 vagina, during the healing of wounds, e.g. after operations 
 on the cervix or vaginal walls ; to apply astringent, anti- 
 septic and anodyne agents ; to get the benefit of the 
 thermal property of the stream. 
 
 Nature of fluids used. — In cases where the influence of 
 heat is not wanted, the fluid need only be warm. When 
 the hot douche is to be taken, the temperature of the fluid 
 should be somewhere between 100° and 120° F. ; it is best 
 that the patient should begin with the lower temperature 
 and gradually increase it. Ordinarily the patient is told 
 to use water as hot as the hand will bear. Cold douches 
 need not be employed. 
 
 Various medicaments are used in certain cases, according 
 
 if 
 
 si -•::ia 
 
 ^ 11 
 
 ^1 
 
 i %\ 
 
 ^1 1 
 
 J; 
 
2l8 
 
 MINOR THERAPEUTIC MEASURES. 
 
 to the nature of the disease, e.g. alum (3 i. to O i.), copper 
 sulphate (3 ss. to O i.), zinc sulphate (Jy ss. to O i.), corrosive 
 sublimate (i in 3000 to 8000), carbolic acid (i in 30 to 60), 
 formalin (i in 1000 to 6000), permanganate of potash, 
 thymol, hydronaphthol, boric acid, etc. 
 
 When, along with the influence of the hot douche, the 
 benefit of an astringent or antiseptic lotion is required, it is 
 best that the patient should first use pure hot water, and 
 immediately afterwards the medicated fluid. 
 
 Frequency of employment. — In the ordinary run of cases 
 the patient is ordered to use the douche both in the morning 
 and evening, or only at one of these times. In special 
 cases it may be necessary to order it to be used more 
 frequently. 
 
 It is important in inflammatory cases that the douche 
 should not be of too short duration. Where the contraction 
 of blood vessels, the relief of congestion, or the promotion 
 of absorption is desired, from two quarts to two or three 
 gallons should be used on each occasion. A considerable 
 quantity should be used when an antiseptic is employed. 
 When a cleansing or an astringent action is desired a couple 
 of pints of fluid usually suffice. 
 
 When a patient is to use the douche on account of its 
 thermic effects for some weeks, she should only gradually 
 work up to the larger quantities. 
 
 Dangers. — In the great majority the use of the douche is 
 not associated with any unpleasant effects. The danger of 
 fluid being forced into the uterus has already been alluded 
 to. Care must be taken to ensure a return outflow from 
 the vagina. 
 
 In acute inflammatory affections, especially of ovaries, 
 bladder, or rectum, the douche must be used cautiously. 
 Pelvic pain may be increased or colicky pain started, faint- 
 ness or marked perspiration is sometimes brought about. 
 When new growths are present care must be taken not to 
 damage the tumour wall and cause haemorrhage. 
 
 I \ 
 
THE VAGINAL PLUG. 
 
 219 
 
 The Vaginal Plug. 
 
 The introduction of a plug into the vagina may be 
 employed for various reasons. 
 
 1. To check haemorrhage, e.g. from the uterine cavity 
 in various conditions. • 
 
 In such a case the most convenient material to employ 
 is iodoform gauze. In introducing it the patient should be 
 placed in either the Sims' or lithotomy position, a speriilum 
 should be passed, and the gauze firmly packed m the vagina 
 from above downwards, the fingers being used for the pur- 
 pose. If the vagina be long or narrow, dressing forceps 
 may be required. 
 
 If an astringent — e.g. a solution of alum or glycerin of 
 tannic acid — be used, along with the plug, the vaginal walls 
 contract more firmly, and the pressure of the plug is thereby 
 increased. Packing may be more easily introduced and 
 removed if the vaginal walls be smeared with an antiseptic 
 vaseline. An antiseptic plug may be left in situ for one, 
 two, or three days. 
 
 If there be retention of urine during this time, the urine 
 should be drawn off. If there be much pain, either an 
 anodyne should be given or the lower end of the plug 
 withdrawn. 
 
 If another plug is to follow, it is well to give the patient a 
 vaginal antiseptic douche before it is introduced. 
 
 2. To keep tents in the uterus, iodoform gauze or a 
 ball of antiseptic wool may be used. The plug need not 
 be large. If the wool be used, a piece of string must be 
 tied around it to aid in its extraction. 
 
 3. To act as a pessary. 
 
 4. To absorb secretions after an operation has been 
 performed, e.g. after an amputation of the cervix. An 
 iodoform gauze plug should be placed against the wound, 
 and left there for twelve or eighteen hours ; afterwards the 
 vaginal douche is used. 
 
 I 
 
 
 fi 
 
 III 
 
 
220 
 
 MINOR THERAPEUTIC MEASURES. 
 
 5. To introduce certain medicinal agents. 
 
 For a considerable period the value of glycerin plugs 
 in the treatment of chronic pelvic inflammation has been 
 recognised. They were introduced by Marion Sims. 
 
 To prepare a plug for use, take a piece of antiseptic 
 absorbent cotton wool, 4 or 5 in. square, and half an inch 
 thick, pour on its centre about half an ounce of glycerin ; 
 fold in the corners, and compress the mass until it is 
 saturated, and then tie a piece of string around it. If 
 necessary, two or more may be tied in series on one 
 piece of string. 
 
 To introduce the plug, the patient is placed in the Sims' 
 or lithotomy position, and a speculum passed. The plug 
 is then pushed well up into the fornix vaginae. 
 
 It may be left in position for twelve to twenty-four hours. 
 It causes a transudation of serum into the vagina from 
 surrounding parts, which is the chief value in the treatment 
 of inflammations. So profuse is the discharge sometimes, 
 that the patient may not be able to walk about without 
 discomfort. In the continued use of plugs they may be 
 introduced two or three times a week. 
 
 In these inflammatory conditions a solution of ichthyol 
 in glycerin, i in 10 to 20, instead of pure glycerin, may be 
 used. Or the following mixture in certain cases :— glycerinum 
 boracis, i part; alum, i part; pure glycerin, 14 parts. 
 
 Other Methods of Medicating the Vagina. 
 
 I. Swabbing 
 
 the walls. — Sometimes it is desired to 
 apply some medicament to the vaginal walls, with the use 
 of douche or plugs — e.g. in granular vaginitis. 
 
 The patient is placed in the Sims' or lithotomy posture, 
 the cavity exposed with spatular specula, and the walls 
 touched by a swab of wool soaked in the medicament. 
 
 A Fergusson speculum can be used conveniently for this 
 purpose. It is passed up to the fornix, and a medicated 
 
 f\ 
 
THE UTERINE DOUCHE. 
 
 221 
 
 \; 
 
 swab on the end of a holder introduced until it touches 
 the cervix. The speculum is withdrawn a little, and then 
 both speculum and swab are slowly withdrawn. The 
 vaginal walls close on the swab as it projects above the 
 end of the speculum, and thus the medicament becomes 
 applied to them. 
 
 2. Powders may be insufflated into the vagina, when it 
 is opened up by a speculum or by the 
 fingers. 
 
 3. Medicated suppositories may be in- 
 troduced, e.g. iodoform suppositories may 
 be used after operations on the vagina 
 or cervix. 
 
 Absorption does not take place through 
 the vagina so quickly as through the 
 rectum. 
 
 \ 
 
 The Uterine Douche. 
 
 In the treatment of various affections 
 of the uterus it is necessary to douche 
 the uterine cavity. The stream of fluid 
 is obtained from a reservoir elevated 
 above the patient. The elevation must 
 be slight, because only a stream of small 
 force is wanted. The instrument, which 
 is passed into the uterine cavity, should 
 be of such a nature as to allow of an 
 easy return outflow through the cervix ; 
 for this purpose the double catheter of Fritsch or Budin 
 is very suitable. 
 
 Method of use. — As the uterine douche in gynecology is 
 generally only used with some operative treatment in which 
 the uterine cavity is involved, it is given when the patient 
 is in the lithotomy position. The vulva and vagina should 
 be thoroughly cleansed. The cervix may or may not be 
 
 Fig. 65.— Fritsch's 
 double catheter. 
 
 
 -iti 
 
 1 71!' 
 
222 
 
 MINOR THERAPEUTIC MEASURES. 
 
 
 i 
 
 Steadied with a volsella. A speculum may or may not be 
 46 introduced into the vagina. The cervix 
 must be large enough to admit the 
 catheter easily without filling it. Arti- 
 ficial dilatation must be used if neces- 
 sary. 
 
 The stream should flow through the 
 instrument before it enters the cervix, 
 in order that no air may be introduced. 
 It must be allowed to enter the uterus 
 slowly. 
 
 Various forms of lotion are used, e.g. 
 boiled hot water; antiseptic solutions, 
 e.g. formalin, boracic, corrosive subli- 
 mate, carbolic, etc. 
 
 The great danger in the use of the 
 uterine douche is that the outflow may 
 be stopped, and the fluid forced along 
 the Fallopian tubes. 
 
 The Uterine Plug. 
 
 In gynecological practice the intro- 
 duction of a plug for any length cf time 
 into the uterine cavity is rarely required. 
 It is used to cause the uterus to con- 
 tract and to check haemorrhage in cer- 
 tain cases, e.g. after the removal of an 
 intra-uterine polypus, sometimes after 
 the removal of an incomplete abortion 
 where the uterine walls are flabby, in 
 some cases of severe bleeding from 
 cancer or sarcoma of the uterus. In 
 such cases it is usually combined with 
 the vaginal plug. 
 In such cases, iodoform gauza is the best material to use. 
 
 Fig. 66. — Budin's 
 double catheter. 
 
THE UTERINE PLUG, 
 
 223 
 
 It should be carefully introduced by means of a speculum 
 and a long pair of forceps. 
 
 In cases in which the cervix is split for stenosis, a small 
 plug of iodoform gauze may be introduced between the raw 
 surfaces for one or more days in order to prevent them from 
 coming together. 
 
 In inoperable cases of carcinoma cervicis, the excavated 
 cavity may sometimes be treated by introducing a plug 
 soaked in some antiseptic and astringent lotion, e.^. liquor 
 ferri subsulphatis (i to 2 of water), or carbolic lotion (i to 
 40) in which is dissolved alum (i of alum to 12 of lotion). 
 In such cases the vagina is packed as well. 
 
 Other methods of applsring medicaments to the uterine 
 cavity. — Besides the use of the douche and of the plug in 
 the special conditions indicated, the following methods may 
 be employed : — 
 
 I. The swab may be used. In order to apply a styptic 
 or an antiseptic to the uterine cavity in diseased conditions 
 or after operations, an ordinary sound or a special vulcanite 
 or metal applicator may be used, its end being covered 
 for an inch or two with a layer of antiseptic cotton-wool ; 
 or a wooden applicator may be employed and afterwards 
 destroyed. 
 
 The patient is placed in the Sims' or in the lithotomy 
 position, a speculum passed, and the cervix steadied with a 
 V Isella. The cervical canal should be large enough to easily 
 admit the sound. After curettings and other operations 
 there is usually no difficulty in regard to this. First a clean 
 dressed sound should be passed to cleanse the cavity. 
 Then the sound, soaked in the desired medicated fluid, 
 should be introduced. In order to make the application 
 to the whole cavity it may be necessary to pass two or 
 three swabs. 
 
 During the application cotton-wool should be held in the 
 vagina, against the cervix, in order to catch any excess of 
 the fluid that may run back from the cervix. 
 
 11 
 
224 
 
 MINOR THERAPEUTIC MEASURES. 
 
 Some of the medicaments employed are an alcoholic 
 solution of iodine (iodine, gr. Ixx. ; iodide of potash, 3iss ; 
 alcohol, ^i), iodo-tannin (a saturated solution of tannin in 
 this iodine mixture), strong carbolic acid, iodised phenol 
 (iodine, 2 parts, with carbolic acid, 8 parts), strong formalin 
 solution. 
 
 To remove the dressing from the sound after use it is 
 best to unroll it between the thumb and forefinger under 
 water. 
 
 2. A small syringe with a narrow nozzle is used by many 
 instead of the swab, especially after curetting, the removal 
 of polypi, etc. 
 
 The patient is placed in the lithotomy position, a specu- 
 lum passed, and the cervix pulled down and steadied with 
 a volsella. The cervical cavity must be large enough to 
 allow of a free return outfloiv alongside the nozzle. The 
 fluid must be injected very slowly. 
 
 The objection to this method is that fluid may be forced 
 along the Fallopian tubes. If, however, the cervical canal 
 be roomy and the injection be made slowly, there is no 
 danger. In many schools it is largely used. 
 
 3. Solid medicaments are seldom introduced into the 
 uterus nowadays. The use of solid caustic is practically 
 given up. 
 
 Sometimes for purposes of antisepsis, iodoform pencils 
 are introduced into the cavity, e.g. after operations on the 
 uterus. 
 
 The Use of Baths. 
 
 In chronic inflammatory pelvic conditions, the judicious 
 use of baths may lead to great improvement in the patient's 
 health. Entire baths may be employed. Such a form of 
 treatment is usually carried out at a watering-place, e.g. 
 Bath, Kreuznach, Kissingen, etc. The benefit derived in 
 such cases is partly due to the improvement in the cir- 
 culation, skin, bowels, kidneys, and other organs from the 
 
 t\ 
 
THE USE OF BATHS. 
 
 225 
 
 action of the baths, but mainly to the changed surroundings 
 of the patient, freedom from care and over-work, regularity 
 and simplicity of life, which are part of the bath-treatment. 
 Various saline waters, e.g. those containing common salt, 
 bromides, and iodides, are mostly employed. 
 
 In the treatment of uterine fibroids, also, similar means may 
 lead to good results. Sea-baths are also good in many cases. 
 
 Hip or sitz baths are also very beneficial. They may be 
 hot or cold, and may be given at special watering-places or 
 at hydropathic establishments, or used by patients at their 
 own homes. 
 
 The hot hip-bath should be taken immediately before 
 the patient goes to bed. The temperature should be 
 the highest the patient can bear comfortably (110° to 
 120° F.). She should sit in the tub so that the water 
 covers the pelvis. Her body should be warmly covered 
 at the time. At first, she should remain in the bath only 
 for a couple of minutes. Afterwards the length of time 
 should gradually be increased, and she can remain seated 
 till the water gets tepid. After the bath, the skin 
 should be thoroughly rubbed, and the patient should go 
 to bed. 
 
 Sea-water may be used, or water in which two or three 
 handfuls of common salt are dissolved. Two or three 
 tablespoonfuls of mustard, also, improve the condition of 
 the water. 
 
 If the patient is using the vaginal douche, it is convenient 
 to take it before she leaves the bath. 
 
 This treatment should be discontinued during menstrua- 
 tion. It is continued according to the nature of the case. 
 Thus, in certain cases of dysmenorrhoea, where the pain 
 occurs just before or at the beginning of the menstrual 
 period, the hip-baths may be taken only for three or four 
 nights before the flow begins. 
 
 In old inflammatory conditions they may be used every 
 other night for one or more weeks. 
 15 
 
 
226 
 
 MINOR THERAPEUTIC MEASURES. 
 
 Cold hip-baths are also valuable as a stimulus to the 
 circulation. They should be taken in the morning. 
 
 Massage. 
 
 The value of massage in the treatment of many bodily 
 ailments has been thoroughly established. In recent years 
 its beneficial influence in many chronic pelvic diseases has 
 been pointed out. Massage may be general or local. 
 
 General massage. — In many cases of neurasthenia in 
 women, from whatsoever cause, the employment of 
 systematic massage combined with seclusion, rest in bed, 
 careful feeding, and, perhaps, electricity, have proved of 
 great value in restoring the patient to health. 
 
 In some of these cases, the advice of the gynecologist is 
 often sought, because one or more of the most prominent 
 symptoms are referred by the patient to the pelvis. There 
 may or may not be any local trouble of importance. If 
 there be none, no local treatment should be undertaken, 
 even though the patient should locate the cause of her 
 illness in the pelvis. Such a case will be best helped by 
 the treatment above indicated, generally referred to as the 
 Weir Mitchell method. 
 
 In this treatment, the skin and muscles of the whole 
 body, and the joints of the limbs, are carefully massaged 
 once or twice a day for half an hour or more at a time ; the 
 course lasts for several weeks. 
 
 In the majority of instances, the patients are restored to 
 health. 
 
 Local massage. — In recent years, owing to the work of 
 Brandt, Hartelius, Nissen, Asp, and others, local massage of 
 the pelvis has been employed by different gynecologists in 
 the treatment of chronic pelvic conditions, e.g. versions and 
 flexions, prolapsus uteri, chronic inflammation, fibroids, etc. 
 
 These various forms are used : — 
 
 External — which consists in the stroking and kneading of 
 
 ' \ 
 
MASSAGE, 
 
 ««7 
 
 the lower abdominal region, the flat hand, the fingers, or the 
 knuckles being employed. 
 
 Bimanual.— \n this, the fingers of one hand are passed 
 into the vagina, into the rectum, or into both of these 
 passages, the outer hand being on the abdomen. The 
 internal finger should not be moved, but should push up 
 and steady the parts which are massaged by the other 
 hand. 
 
 These forms of massage should last only ten or fifteen 
 minutes. The periphery of swellings should be first mani- 
 pulated. 
 
 Passive. — This consists merely in exercising steady pres- 
 sure or traction on adhesions. This method should last 
 only a few minutes. 
 
 After massage, the patient should lie quiet for a little. 
 
 It is always well that this form of treatment should be 
 combined with the use of vaginal douches and baths. The 
 introduction into the vagina of dilators, e.g. Bozeman's, or 
 of vulcanite plugs like those of Prochownik, for a few hours 
 in the day, in cases of pelvic adhesions, may help to soften 
 and stretch the tissues, and so will aid the massage. 
 
 Conira-indications. — All acute inflammations, menstrua- 
 tion, pregnancy, phthisis, distended tubes. 
 
 Expediency of local massage. — Though the circulation of 
 blood and lymph is undoubtedly benefited, and though the 
 absorption of exudations may be promoted, I think the 
 dangers to the woman's psychical organisation are too great 
 to admit the rr hod of pelvic massage to a place among 
 the therapeutic agencies of the gynecologist. It is stated 
 by those who practise this system, that the manipulations 
 require to be carried on for weeks or months. This is 
 sufficient, in my mind, to condemn the method. Stimu- 
 lation of the sexual centres cannot fail to be brought about, 
 and, as a result of this, the patient may suffer in various 
 ways. I believe that there is scarcely a case in which 
 massage is at all necessary. Equal or better results can be 
 
 !iH 
 
 '. ; 
 
328 
 
 MINOR THERAPEUTIC MEASURES. 
 
 obtained by other therapeutic means. A striking example 
 of this is seen in the treatment of prolapsus uteri. Brandt's 
 massage method in the treatment of this condition is as 
 follows : — 
 
 The patient, with loosened clothes, lies on a table or 
 couch, cushions being placed under her chest. An assistant 
 passes his fingers into the vagina, and pushes the uterus 
 upwards and to the front. It is then drawn up as far as 
 possible. The woman next supports her body on elbows 
 and feet, while the physician forcibly separates and closes 
 her knees three times. This method is troublesome and 
 unpleasant to the patient, and is of very little value. By 
 pessaries or operation much surer benefit may be derived. 
 
 Schultze's method. — Schultze recommends the breaking- 
 down of adhesions under chloroform. 
 
 This plan has not been much tried. It should be prac- 
 tised with great care. There is considerable risk of setting 
 up haemorrhage or of injuring viscera. Above all, the 
 physician should feel very sure that the tubes are not 
 distended;, and that there is no pus collection anywhere 
 in the pelvis. 
 
 The Thermo-Cautery. 
 
 The thermo-cautery is valuable in certain cases. It may 
 be used to remove urethral caruncles, small growths on the 
 vulva, piles ; to open abscess cavities and cysts of the vulva, 
 to puncture and destroy Nabothian follicles, etc. It is also 
 used as a haemostatic on wounded surfaces. 
 
 histrument. — Paquelin's cautery is the best form. The 
 cones are kept hot by the burning of benzoline vapour, 
 which is pumped continuously through the hollow handle. 
 Cones of various sizes and shapes may be obtained. , 
 
 Before pumping the vapour, it is necessary to heat the 
 ^nd of the cone in a flame. Care should be taken not to 
 bring the reservoir of benzoline near a flame. 
 
 IV 
 
V- 
 
 THE CAUTERY. 
 
 229 
 
 The cautery should be used when the cone is dull-red in 
 colour. If white-hot the haemostatic action is lost. 
 
 A button-cone may be used with this cautery if applica- 
 tions are to be made to the spinal region. 
 
 The Electro-Cautery. 
 
 Skene advocates the use of forceps, heated by an electric 
 current, for the purpose of closing vessels. The heat is 
 used to desiccate or dry the tissues without charring them. 
 He employs a clamp, in the same way, for the purpose of 
 dividing the pedicle of a tumour, e.g. an ovarian, and in 
 dividing the broad ligaments in vaginal extirpation of the 
 uterus. The required temperature varies from 170° to 
 190° F. 
 
 Abdominal Bandages. 
 
 Abdominal bandages may be of service in various con- 
 ditions, e.g. pendulous belly, with or without pregnancy, 
 tumours of large size in the abdominal cavity, floating 
 kidney, after operations on the abdominal wall, after 
 abdominal section, after child-birth, in separated recti, 
 and umbilical hernia. Abdominal bandages may also be 
 used to keep dressings over the genitals, to hold vaginal 
 pessaries, etc. The most common form used after opera- 
 tions is a wide bandage, made of domette or of linen, long 
 enough to encircle the abdomen and pelvis with the dress- 
 ings, and to overlap. It should reach from the level of the 
 great trochanters to near the ensiform cartilage. The dress- 
 ings of wool should be so distributed as to allow of equable 
 pressure by the bandage. With such a bandage, the 
 patient must remain as quiet as possible in bed. It is 
 very apt to slip upwards. 
 
 When a patient has to wear a bandage, e.g. in a case of 
 pendulous belly, while she moves about, such a form is not 
 convenient, because it tends to become greatly wrinkled 
 
 ^ ,1 
 
 ;■ i 
 
 
 « J ):tt| 
 
»\ 
 
 SJO 
 
 MINOR THEKAPEUTIC MEASURES. 
 
 and to slip. It can be much improved by the addition 
 of shoulder and thigh straps. In all such cases special 
 bandages made of elastic material, or containing elastic, 
 should be employed. Support is needed, particularly for 
 the lower abdominal region. 
 
 Complete elastic bandages may be used ; they are slipped 
 on ovei the legs. But more convenient are the forms 
 which can be strapped on one side or at the back. 
 
 When the bandage is only partly elastic, the elastic 
 portion may be in front, behind, or at the sides. The 
 lower border should fit rather tightly, in order that it may 
 not easily slip up. To prevent creasing and slipping 
 upwards with certainty, it is a good thing to attach 
 thigh-bands to the bandage. These may be made of silk, 
 covered cloth, or, bettf i, of rubber. These must not fasten 
 too near the middle line, or the bands will tend to slip into 
 the fold between the nates. The chemise should be worn 
 under the bandage. 
 
 For floating kidney a similar bandage may be used, 
 aloiig with a hard cushion of wood, vulcanite, or metal, 
 covered with leather, attached to the spot over which the 
 special pressure is to be made. Or a mere abdominal belt 
 with the cushions attached may suffice, if, in addition, 
 thigh-bands be used to keep the belt in position. Also, 
 a cushion may be kept in position by a truss-like arrange- 
 ment. 
 
 Abdominal bandages are also used for the purpose of 
 keeping dressings in the vulvar or sacral region in position. 
 The commonest form is the well-known T bandage. A 
 special bandage may be obtained ; it consists of an 
 abdominal girdle with four straps attached, two in front, 
 and two behind. These straps support a pad which rests 
 against the perineum. 
 
 Dressings may be kept in place by straps of adhesive 
 plaster, unless the patient objects strongly to their use. 
 
 Abdominal bandages are of service in giving attachment 
 
rESSAR/ES. 
 
 m 
 
 to certain vaginal i)essaries, or perineal supports, in cases of 
 bad prolapse of the uterus or anus, when the patient will 
 not allow operative measures to be employed. 
 
 Pessaries. 
 
 During the last few years the opinions of many of the 
 leading gynecologists have undergone a marked change with 
 regard to the value of pessaries in the practice of gynecology. 
 
 Fig. 67. — Hodge and Albert Smith pessaries. 
 
 Many forms of pessary have been devised during the pre- 
 sent century, and their claims have been advocated by many 
 physicians of greater or less renown. To refer to them 
 many pages would be needed, and though such a survey 
 might prove interesting, it would scarcely be suitable for a 
 practical treatise at the present time. 
 
 Owing to comparatively recent researches, whereby we 
 have acquired much accurate knowledge regarding the 
 physics of the pelvis, the normal relations and movements 
 of the various parts of the pelvic floor, the real significance 
 of their various displacements and the correct estimation of 
 
 !> fli 
 
 
 
 n 
 
 
 II 
 
 i -' 
 
 
 s I 
 
 i\\\ 
 
 M 
 
232 
 
 MINOR THERAPEUTIC MEASURES. 
 
 Fig. 68. — Thomas' pessary. 
 
 the symptoms caused by them, the employment of pessaries 
 has been largely lessened. Of very great importance also 
 in bringing about this change, are the advances which have 
 been made in the operative treatment of some of the con- 
 ditions for which pessaries have long been used. 
 
 Forms of pessaries. — Hodge's 
 pessary is a valuable one. It con- 
 sists of two parallel side-bars joined 
 at the lower end by a straight cross- 
 bar, and at the upper end by a 
 curved bar, whose concavity looks 
 towards the lower end of the 
 pessary. When viewed from the side, it has a sigmoid 
 curve, in order that it may, when in position, fit the vagina 
 properly. It is best thus made of vulcanite, because it is 
 pliable if placed in hot water for a little, and so can be 
 moulded to any desired shape; it gets firm again when 
 cold. 
 
 Vulcanite does not get soiled as does guttapercha, and it 
 does not soften in the vagina so easily 
 as celluloid. 
 
 The pessary can be obtained in 
 various sizes, and with different de- 
 grees of sigmoid curve. Very often 
 the upper end curves too markedly 
 forward. 
 
 Albert Smith's pessary consists of two 
 lateral bars joined by rounded ends. 
 The bars are not parallel, but are wider 
 apart at the upper end of the instrument than at the 
 lower. Viewed laterally it has the sigmoid curve. It is best 
 made of vulcanite. Very often this pessary is made too 
 markedly curved forwards at the upper end, and the lower 
 end is in many too pointed. It is then apt to slip out of 
 the vagina if the introitus is wide, and is liable to interfere 
 with coitus. 
 
 Fig. 69. — Ring 
 pessary. 
 
 \ \ 
 
PESSARIES. 
 
 233 
 
 Both of these pessaries may be obtained with transverse 
 bars across their lower part. 
 
 Gaillard Thomas' or Munde's pessary is somewhat similar 
 in shape, but the upper end is thick. It may be made of 
 vulcanite or of guttapercha ; when of the latter, this end 
 forms a soft cushion, which fills the posterior fornix when 
 the instrument is in position. 
 
 Schnltze's figure-of-eight pessary is greatly used in Germany, 
 but I has no advan- 
 tages over the above- 
 mentioned forms. 
 
 The ring pessary is 
 made of various ma- / 
 terials, e.g. wood, vul- 
 canite, metal, india- 
 rubber. The most 
 convenient are the 
 indiarubber forms. 
 Some are hollow, con- 
 taining a spring, others 
 are of solid rubber. 
 
 The diaphragm-ring 
 is simply the last-men- 
 tioned form, with a 
 perforated rubber dia- 
 phragm. 
 
 Ball or egg pessaries are made of vulcanite or wood. 
 
 The Zwanck or Zwanck-Schilling pessary consists of two 
 perforated wings of vulcanite or metal, connected by a 
 hinge joint. At right angles to them run bars, which are 
 joined to a screw-stem. By means of the screw the wings 
 can be opened out or brought together. 
 
 Vagino-abdominal pessaries are those which, thougli meant 
 for the vagina, are kept in position by means of abdominal 
 support. There are various forms of these. Cutter's may 
 be taken as a type. In it there is a curved stem, which is 
 
 Vio. 70. — Zwanck's pessary. 
 
 I 
 
 i 
 ! 
 I 
 
 ll :*.-j.j| 
 
 i ill 
 
 1^ \ 
 
w 
 
 234 
 
 MINOR THERAPEUTIC MEASURES. 
 
 fastened to an abdominal belt in the middle line of the back, 
 passes down over the sacral region, anus and perineum, into 
 the vagina^ where it supports a cup on which the uterus rests. 
 Method of using pessaries. — Preliminaries. — A careful 
 bimanual examination must be made in order to determine 
 the special requirements of the case, as well as the size of 
 the instrument necessary. If the uterus be retroverted, it 
 must be turned so that the fundus looks towards the front, 
 by means of the sound, or by the fingers, assisted by the 
 genu-pectoral posture. The patient is then placed on her 
 left side, with the knees drawn up, under cover of a sheet. 
 
 Introduction of instrument. — {a) 
 Hodge, Albert Smith, Thomas or 
 Munde pessary. 
 
 The lower end is grasped between 
 thumb and forefinger of the right 
 hand, the upper end having been 
 greased with vaseline. The labia are 
 separated posteriorly with the fingers 
 of the left hand. When the introitus 
 is narrow, the perineum is pulled 
 back. The instrument is then intro- 
 duced, with its plane surface, in line 
 with the vulvar slit, i.e. parallel to the 
 table. It is directed backwards towards 
 the sacral hollow, until it is little more 
 than hair within the vaginal orifice. 
 The right index-finger is then placed under the pessary against 
 the upper bar, and the instrument is rotated so that its plane 
 surface lies parallel with the vaginal walls. It is then pushed 
 upwards until the upper end rests in the posterior fornix. 
 
 In pushing it upwards the finger must be directed well 
 backwards in order to oppose the tendency of the instru- 
 ment to slip into the anterior fornix. The most difficulty is 
 found where the vagina is narrow, and the parts rigid. No 
 pain should be caused by the introduction. 
 
 Fig. 71.- 'chultze's 
 pessary. 
 
 ' t 
 
PESSARIES. 
 
 23s 
 
 ip) Ring pessary. — This form is introduced in much the 
 same manner as that just described. When a soft, rubber 
 ring is used, it is compressed by the thumb and forefinger 
 of the right hand while it is being passed through the vulva 
 in order not to stretch the parts and cause pain. 
 
 {c) Zivanck pessary. — The wings are brought together, 
 and are then passed into the vagina. The screw of the 
 handle is then turned so as to cause the blades to be 
 separated sufficiently to enable the instrument to remain 
 in position. 
 
 After-considerations. — When the pessary has been passed 
 the patient is asked if she feels any pain or discomfort, and 
 she is made to press down or to cough, in order to determine 
 how the pessary fits. She then rises, and is tested standing 
 erect, with her body bent at right angles to her limbs, in the 
 position of micturition (if necessary), and walking. 
 
 The lower end of the instrument must not project beyond 
 the vulva — must not press against the symphysis. It should 
 lie just within the introitus, and should not press hard 
 against the urethra. The upper end should not push up 
 the fornix unduly. The vagina must not be stretched 
 transversely by the Hodge, Smith, Thomas or Munde 
 forms. With the others it must not be too much stretched 
 in this direction. The patient should be instructed to 
 return if she is troubled with discomfort or pain while 
 wearing the instrument. 
 
 If the woman douches, the pessary need not be removed 
 and cleansed oftener than once in eight or ten weeks, if it be 
 of vulcanite ; sodium bicarbonate in the douche has a cleans- 
 ing action. Removal should be more often in the case of 
 soft rubber, though it is difficult to get patients to bother 
 to return in order to have the instruments changed. The 
 pessary may be worn for months, or for more than a year, 
 according to the necessities of the case. 
 
 Contra-indications to the use of pessaries. — Fixation of the 
 uterus, so that the fundus cannot be turned to the ^.ont. 
 
 iiii 
 
 .1 
 
 ; i 1 ' 
 
 I 
 
 ill 
 
 i ■■'■ t ? 
 
 < ; •■ 
 
 •5 ;'■" 
 
vS 
 
 236 
 
 MINOR THERAPEUTIC MEASURES. 
 
 \ 
 
 Interference with the mobility of the uterus, as a result of 
 some swelling, e.g. tumour of ovary, etc. Recent acute 
 inflammation in any of the pelvic tissues or viscera. 
 Tenderness of the vagina from vaginitis. Certain tumours 
 of uterus or of vaginal wall. 
 
 Some ill-effects of pessaries. — Pain may result. The 
 functions of the bladder or of the rectum may be inter- 
 fered with. Ulceration of the vaginal walls or cervix may 
 occur. Perforation of the rectum, of the bladder, or of 
 
 both, may take place. 
 Coitus may be made dif- 
 ficult. 
 
 These troubles may re- 
 sult from pessaries when 
 they are too large, when 
 misplaced, when not kept 
 clean, when worn too long 
 without change, or when 
 some contra -indication 
 has not been regarded. 
 
 Mode of action of pes- 
 saries. — I. Pessaries of 
 the Hodge type. 
 
 It used to be taught 
 that when this pessary 
 is in position the intra- 
 abdominal pressure acts chiefly on the lower end of 
 the instrument, thus pushing it downwards, and causing 
 the upper end to rise and move somewhat forwards in the 
 posterior fornix, thus pushing the uterus forwards. This is 
 not the explanation. When the pessary is in position it lies 
 in the vaginal slit between the pubic and sacral segments. 
 Intra-abdominal pressure acts at right angles to every point 
 of the floor, and consequently acts with equal force on all 
 parts of the pessary. 
 
 The pessary acts in two ways : — 
 
 Fig. 72. — Pessary (Thomas') in position. 
 
 fv 
 
PESSARIES. 
 
 237 
 
 {a) It helps to keep up the uterus as a whole, thus 
 tending towards the relief of the congestion of the organ. 
 
 {b) The upper end of the pessary affords a support over 
 which the posterior vaginal wall pulls on the cervix in an 
 upward and backward direction, the body of the uterus 
 consequently tending to be kept forwards. In fact, this 
 action makes up for the loss of function in the utero-sacral 
 ligaments which, in the normal state, draw the cervix 
 upwards and backwards, but which in cases of retroversion 
 of any length of duration lose this power through the 
 stretching to which they are subjected. 
 
 2. Ring pessaries act merely as a general means of 
 support. They lie between the pubic and sacral segments, 
 stretching the vagina more or less. They tend to prevent 
 the vagina or uterus from becoming prolapsed. The ring 
 does not act in the posterior fornix like the Hodge pessary 
 in the majority of cases. Sometimes, it may have this 
 action, and prevent the uterus, which has been replaced, 
 from becoming retroverted again. 
 
 3. Zwanck's pessary acts in virtue of the width of its 
 wings. These remain in the vagina, and tend to keep the 
 uterus from descending. Patients sometimes prefer this 
 instrument because they can so easily introduce and 
 remove it. 
 
 4. Ball pessaries act merely through occupying a large 
 amount of space in the vagina. 
 
 5. Vagino-abdominal pessaries keep up prolapsing parts, 
 by means of the suspension from the abdominal band. 
 
 The Use of Electricity. 
 
 The exact value of galvanic electricity as a therapeutic 
 agent has not yet been definitely established. By some 
 authorities it is employed to an enormous extent in 
 their practice, by others it is not at all used, and by others 
 it is used to a very limited extent. One school holds that 
 
 
 
 1^ 
 
v\ 
 
 238 
 
 MINOR THERAPEUTIC MEASURES. 
 
 in certain cases, e.g. fibroid tumours, its action may lead to 
 the disappearance of the abnormal growth ; another holds 
 that it is merely to be ranked among other methods of 
 bringing about improvement in certain symptoms. 
 
 One great objection to its use is the time and trouble 
 required. 
 
 Apparatus employed.— T\\q galvanic current is produced 
 by the action of certain solutions on two different metals. 
 In practice, batteries of different sizes are used. It is con- 
 venient to employ one in which a considerable strength may 
 be obtained. Stationary or movable batteries may be used. 
 They are usually in the form of a cabinet. Each battery 
 must possess apparatus by which different numbers of cells 
 may be connected with the circuit. 
 
 There should be a galvanometer, an indicator of the 
 nature of the two poles, a current interrupter, and a 
 commutator, which enables the current to be quickly 
 altered. With these batteries also the necessarv apparatus 
 for producing faradism or electric illumination may be 
 employed. 
 
 The rheostat, an instrument which alters the strength of 
 currents by placing resistances in the line of the currents, 
 may also go along with the battery. It is useful in allowing 
 the current to be gradually increased or diminished with- 
 out the slightest shock, and thus serves well with nervous 
 patients. 
 
 Different forms of terminals or electrodes are employed 
 to bring the current into relationship with the diseased 
 tissues of the pelvis. Electrodes are external and internal. 
 The external electrode is generally applied to the lower part 
 of the abdomen above the pubes, where direct electrical 
 action is required ; sometimes over the sacrum, where in- 
 direct action is wanted. They may be made either of wet 
 potter's clay, half an inch thick, or of block tin or lead, 
 perforated with small holes and lined with a layer of cotton 
 wool, chamois leather, or rough towel cloth. These elec- 
 
 ! \ 
 
ELECTRICITY. 
 
 239 
 
 trodes vary from 4 to 10 in. in diameter. The smaller 
 they are the more the patient is apt to feel [)ain. Before 
 use it should be moistened in warm water. It should be 
 kept steady while the current is i)assing by a bandage passed 
 lightly around the abdomen. 
 
 Internal electrodes are used in the vagina, in the uterus, 
 in the bladder, in the rectum, or in the substance of masses, 
 e.g. certain fibroids. Most commonly vaginal ones are 
 employed. 
 
 Vaginal, rectal, and vesical electrodes are of various 
 shapes and sizes, e.g. round, bulbous, or elongated. The 
 staff on which they are held should be covered with 
 vulcanite or rubber tubing to insulate it. 
 
 For the vaginal portion of the cervix a cup-shaped end 
 may be used. For the uterine cavity various forms are 
 used. The most common is that shaped like a uterine 
 sound. Platinum ends should be employed ; the positive 
 pole will not corrode this metal, nor gold nor aluminium. 
 For puncture of tissue a steel needle is used. 
 
 Action of galvanic current. — It is taught that there is 
 a polar action chemical in nature, that at the positive end 
 differing from that at the negative ; and, also, an interpolar 
 action as the current flows from one pole to the other. The 
 effects depend upon strength of current and duration. 
 
 The effect of the positive pole is described as the harden- 
 ing, coagulating, and haemostatic one ; it is less painful than 
 the other pole. The effect of the negative pole is said to 
 be to disintegrate tissue, to cause congestion, to favour 
 haemorrhage ; it is the caustic, painful pole, being more 
 active chemically than the positive. 
 
 Puncture of tissue is carried out chiefly in cases of 
 fibroids where a sound cannot be passed into the uterine 
 cavity. But it may be combined with intra-uterine elec- 
 trisation. 
 
 Faradic electricity. — This may be used externally, inter- 
 nally, or both externally and internally. Where the internal 
 
340 
 
 MINOR THERAPEUTIC MEASURES, 
 
 application alone is used, a double electrode, with an insu- 
 lator between, may be employed. 
 
 The chemical action resulting from faradic electricity is 
 very slight. It has mainly a stimulant and contracting 
 effect. 
 
 Nature of applications. — The patient should be douched 
 before and after the application with an antiseptic. She 
 should rest for a little afterwards. The length of the applica- 
 tion is from five to eight minutes in most cases. Where 
 pain is being treated the applications may be longer. They 
 niay be given daily, every other day, or twice a week, 
 according to the conditions present. Various strengths 
 of currents are used. The highest limit may be con- 
 sidered 300 milliamperes. A very common range is from 
 50 to 150. 
 
 Conditions in which Galvanism has been 
 Recommended. 
 
 Uterine atrophy, superinvolution, infantile uterus, 
 
 associated with amenorrhoea and local loss of tone. 
 
 Faradic or galvanic electricity may be tried externally, or 
 best, both externally and internally at the same time. In 
 virgins it may be impossible to carry out the internal 
 application. When the faradic current is used it does not 
 matter which pole is in the uterus or vagina. When the 
 galvanic is used, there is a difference of opinion as to which 
 should be introduced ; the current should not be strong. 
 
 Dysmenorrhoea associated with, or without, local inflam- 
 matory conditions. In these cases, the combined external 
 and internal galvanic currents of mild strength are used, 
 the positive pole being internal. In virgins it may only be 
 possible to make external application. 
 
 Myoma uteri. — The galvanic current is used. The 
 internal electrode is placed in the uterine cavity when pos- 
 sible, and is the negative pole unless it is a hsemorrhagic 
 
GALVANISM. 
 
 HI 
 
 case, when the posterior pole is placed there ; or the inner 
 electrode may penetrate the tumour for i to 2 in. The 
 puncture is made on a part of the fibroid within easy 
 reach. Vessels of any size should not be wounded, if 
 possible. The puncture is usually made with the negative 
 pole. The most thorough antiseptic precautions must be 
 observed. 
 
 Puncture of the tumours through the abdominal wall is 
 to be deprecated. 
 
 Metritis, endometritis may be benefited. 
 
 Chronic cellulitis, chronic ovaritis, salpingitis, peri- 
 metritis, periovaritis, old haematocele, and perisalpingitis 
 are often improved. Also pelvic pains in neurotic patients 
 may be helped by applications. The negative pole is 
 usually placed in the vagina. 
 
 Affections of the rectum. — Electricity is used by some in 
 the treatment of haemorrhoids and of prolapse of the bowel. 
 The galvanic current may be passed, one pole being on 
 the abdomen the other in the rectum. Where the piles 
 are large, electro-puncture with the positive pole may be 
 used. 
 
 Faradism of the bowel is recommended for chronic con- 
 stipation by some. 
 
 Bladder troubles. — For irritability or incontinence, ab- 
 domino - spinal, abdomino - vaginal, or abdomino - urethral 
 applications of galvanism may be employed. When there 
 is hypersensitiveness of the neck of the bladder, the positive 
 pole is passed as far as this region. 
 
 Ectopic pregnancy. — The value of electricity in destroy- 
 ing an ectopic pregnancy has not yet been definitely 
 ascertained. Some authorities would never employ it, 
 others believe in using it during the first three months of 
 pregnancy. Faradism and galvanism have both been used. 
 The patient should be in bed. One electrode — the negative 
 — is placed in the rectum or vagina, the outer on the 
 abdomen over the cyst. 
 16 
 
 lit 
 
242 
 
 MINOR THERAPEUTIC MEASURES. 
 
 Contra-indications and dangers. — The electrical treat- 
 ment should not be carried out where there is any acute 
 inflammatory condition in the pelvis. Nor is it advisable 
 where there is any collection of pus. In some cases it may 
 be advisable not to employ it if the patient is particularly 
 sensitive. 
 
 We are not yet sufficiently aware of the dangers that may 
 result from the use of electricity, even in supposed suitable 
 cases. Pelvic inflammation may undoubtedly be set up. 
 Haemorrhage may be started. This may result from the 
 influence of the negative pole, from irritation of the uterine 
 mucosa, or from the perforation of a large vessel when 
 electro-puncture has been tried. Septic infection may be 
 caused. 
 
 Points to be attended to during the application. — The 
 patient must be placed in the dorsal position. It is well 
 to assure her that the application will not be of the nature 
 of a shock. The clothing is loosened, and the external 
 electrode is placed on the abdomen and kept steady by the 
 use of a lightly-applied bandage. This should be allowed 
 to remain for a little before the current is passed in order 
 that the skin may be well moistened. If there is dryness, 
 more pain will be caused. Any abrasion of the skin should 
 be protected with oiled silk. The electrode should be 
 covered with a dry piece of cloth or of oiled silk to protect 
 the clothes from moisture. The internal electrode is then 
 introduced, the vagina having been cleansed before the 
 patient has lain down. The end of the electrode should 
 be cleansed and dipped in an antiseptic solution. It is 
 introduced as a uterine sound would be, being guided by 
 fingers placed in the vagina. There should be little or no 
 pain in introducing the instrument. If electro-puncture 
 is to be made, the uterus must be steadied through the 
 abdominal wall. The wires are now attached to the 
 electrodes, the condition of the apparatus having been tested 
 beforehand. The galvanometer needle is at zero. 
 
GALVANISM. 
 
 243 
 
 The outer electrode may now be lightly pressed against 
 the belly by the patient's or by a nurse's hands. The elec- 
 trodes must be steady, and the legs should not be allowed 
 to touch them. 
 
 It is best not to employ a vaginal speculum. If it must 
 be used, the electrode must not touch it, or a shock will be 
 caused. Neither must it be allowed to burn the vaginal 
 wall. 
 
 No sudden shock must be allowed, e.g. by the slipping 
 of a wire from a screw. In stopping the application it is 
 best gradually to reduce the strength by turning off the 
 current bit by bit, or by increasing the resistance by the 
 rheostat, until the galvanometer points again to zero. The 
 wires are then removed, then the internal electrode, then 
 the outer. The vagina is then cleansed. After puncture a 
 styptic may be used and a vaginal plug. The patient must 
 rest afterwards. 
 
 (For full details regarding the use of electricity, the works 
 of Apostoli, Engelmann, Cutter, Keith, and others may be 
 referred to.) 
 
 
 vM 
 
v\> 
 
 CHAPTER IX. 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 Asepsis and Antiseptics. 
 
 A WOUNDED surface may be infected with germs or their 
 products in the following ways : — 
 
 By the hands of the operator, of his assistants, or of 
 nurses. ' ' 
 
 By means of instruments, apparatus, and other parapher- 
 nalia used in the operation. 
 
 Owing to the non-cleansing of the patient. 
 
 By means of the air. 
 
 In gynecological operative work, as in all surgical work, 
 our aim should be not merely to use antiseptics, but so to 
 handle the patient as to keep every wounded surface aseptic 
 from the beginning of the operation until the end of the 
 repair process, which leads to the closure of the wound. In 
 the later stages of the evolution towards what is now known 
 as aseptic surgery, the part played by antiseptics is more 
 restricted than in the early Listerian days. 
 
 It is necessary that every operator should thoroughly 
 master the details of the modern method of clean surgery. 
 There is no doubt that partial knowledge may in certaini 
 cases lead to errors as serious as those which proceed from 
 ignorance. Thus an operator may take a piece of silk 
 ligature from a drawer, soak it for a few minutes in i in 30' 
 carbolic solution, or i in 2000 corrosive sublimate, and then 
 use it as a suture, under the belief that he has satisfied all 
 
 iv 
 
ASEPSIS AND ANTISEPTICS. 
 
 345 
 
 the requirements of the aseptic system. Such a proceeding, 
 in th(i light of present knowledge, is as serious as if he 
 were to pick a suture from the floor and use it. Because 
 it has been shown that certain micro-organisms will not be 
 destroyed by these solutions unless left soaking in them for 
 hours. Then, again, some think that if ligatures or instru- 
 ments are placed in water raised to the boiling-point for 
 a minute or two, all germs and spores will be destroyed. 
 This is well known not to be the case. Then, again, many 
 believe that certain dry dressings which are impregnated 
 with antiseptics, now so largely used, are all powerful 
 destroyers of germs ; whereas, in reality, it is only when 
 in contact with liquids that their activity is shown. It is 
 evident, then, that dry dressings, unless sterilised immedi- 
 ately before application to wounds, may be carriers of living 
 germs and spores. 
 
 It is necessary, therefore, to study the best means of 
 carrying out all operative procedures, in order that the wound 
 may not become infected. 
 
 The operator, assistants, and nurses. — The operator 
 should not, immediately previous to the operation, have 
 visited any infectious case, nor have been in contact with 
 putrefying organic matter, e.g. post-mortem specimens. 
 
 Before all major operations, it is advisable that a special 
 clean suit of linen clothes should be put on. It is, however, 
 considered by some sufficient to remove the coat, roll the 
 shirt sleeves up as far as the shoulder, and to envelop the body 
 in a long sterilised apron, with short sleeves, which fastens 
 behind. This apron should be waterproof. Some operators 
 prefer to wear a sterilised linen or cotton apron outside this. 
 
 To cleanse the hands and arms, turpentine, soap, and 
 warm running water should be first used, the skin and nails 
 being carefully cleaned with a brush. Many operators follow 
 the plan, after washing, of soaking the arms and hands in a 
 solution of permanganate of potash, and afterwards in one 
 of oxalic or sulphurous acid. Then the surface should be 
 
 if! 
 
 
 
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 W. ''I, 
 
 '■|; • 
 
 ■-. i '-A 
 
 : ■ ? n 
 'ill 
 
 ■i: ■-':t\ 
 
 i Pf if 
 
246 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 well brushed with i in 1000 acid corrosive sublimate solu- 
 tion, I in 500 formalin solution, i in 1000 iodic hydrarg. 
 solution, or i in 100 warm lysol solution. They may 
 afterwards be soaked in these solutions for a little before 
 the operation is begun. Alcoholic solutions of the mercuric 
 salts are probably better than watery ones. 
 
 During the operation the hands should be washed from 
 time to time in one or other of these lotions. In abdominal 
 sections, however, weaker lotions should be used as a rule, 
 or only sterilised water. 
 
 Every assistant and nurse who may touch the wound, or 
 handle anything which comes into contact either with the 
 operator's hands or with the wound, should cleanse hands 
 and arms in the same manner as that just described. 
 
 The most glaring faults may be committed through non- 
 attendance to this rule. Thus one may see a nurse looking 
 after dressings, sponges, or instruments, with the sleeves of 
 her dress scarcely raised above the wrist -, and in the intervals 
 of her occu^ ation she may be noticed to pull up the sleeves 
 from time to time. Or she may rush to secure an arm or 
 leg of the patient which has broken loose. Or she may 
 carelessly place the dressings on her sleeve before passing 
 them to the operator. In the training of nurses it is most 
 important that they should be taught the necessity of 
 attention to minutiae. They should, moreover, have a 
 thorough understanding of the rationale of the aseptic 
 system, in order that they may work intelligently. 
 
 Instruments, apparatus, swabs, ligatures, etc. — 
 {a) Instruments. — Instruments should be made as simple as 
 possible in order to afford no gathering-places for germs. 
 They should be made entirely of metal where possible. 
 All locks should be separable. By careful scrubbing and 
 no''.shing, all gross or perceptible dirt can be removed from 
 them. Before they are used in operations, they require to 
 be made aseptic. 
 
 Sterilisation is most surely carried out by means of heat. 
 
ASEPSIS AND ANTISEPTICS. 
 
 247 
 
 A dry heat of iso'-iSo" C, kept up for a few minutes, will 
 suffice. Moist heat is more efficacious. Compressed cir- 
 culating steam at 130° C. will destroy all micro-organisms 
 and spores. 
 
 Various forms of sterilising chambers are used. These 
 methods cannot in all cases be easily carried out. A simple 
 substitute consists in boiling the instruments. Half an 
 hour's boiling will ensure complete disinfection. According 
 to Tavel, less time is required with a f per cent, solution 
 of common salt. If sodium carbonate (exsiccated) be added, 
 sufficient to make a \ per cent, solution, the instruments 
 will not rust. 
 
 After being sterilised, the instruments should be placed, 
 during the operation, in an antiseptic lotion, e.g. i in 40 
 carbolic, i in 200 lysol, i in 4000 hydronaphthol, or i in 40 
 boric, I in 4000 formalin. Some operators use plain steril- 
 ised water. 
 
 After operations, the instruments should be thoroughly 
 washed in warm soap and water, sterilised, and then dried. 
 
 Drainage-tubes should always be kept in a jar of antiseptic 
 solution. 
 
 Rubber articles should not be boiled. Dishes which hold 
 instruments should be made of glass or porcelain. 
 
 {d) Apparatus. — All basins, ewers, douche tubes, etc., 
 which may be used by operator, assistants, or nurses, or 
 which may be brought near the wound, should be thoroughly 
 washed beforehand in a strong antiseptic lotion, e.g. i in 500 
 corrosive sublimate, i in 500 formalin, i in 20 carbolic, etc. 
 
 {c) Gauze^ cottofi-ivool swabs, ligatures, towels. — Sponges 
 are now almost entirely unnecessary in gynecological opera- 
 tive work. Instead, pieces of gauze or cotton-wool, medi- 
 cated or not, are used TTor abdominal sections, prepared 
 pieces of gauze are . ^ oest ; a square is made of eight 
 thicknesses of gam 2, each side measuring about 10 in., 
 the edges being hemmed. Or they may be made of rolls of 
 wool enclosed in sewed bags of gauze. 
 
 If; 
 
248 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 
 These swabs must either be sterilised by moist air or 
 boiled for half an hour in the above-mentioned soda-salt 
 solution. Afterwards they may be kept in carbolic, formalin, 
 or other antiseptic lotions. Before use they may be soaked 
 in sterilised water and thoroughly squeezed. They may 
 be used several tinies during an operation if the blood 
 be washed out. But if any dirty matter like pus touches 
 them, they should be at once thrown into the fire. 
 No swabs should be used in more than one opera- 
 tion. 
 
 All towels and cloths used during the operation should be 
 sterilised in the moist-air chamber or boiled for half an hour 
 in the soda-salt solution, afterwards being wrung out of an 
 antiseptic lotion or used in the dry state. 
 
 Silk ligatures are to be boiled in the same manner, and 
 then placed in an antiseptic lotion. 
 
 Catgut ligatures are prepared in various ways. The best 
 are chromic gut and gut prepared in the oil of juniper wood. 
 Before being used they should be washed in ether, and thcii 
 thoroughly soaked in an antiseptic solution, e.g. i in looo 
 iodic hydrarg. It is well to have a small supply constantly 
 soaking in the antiseptic. 
 
 Sponges should be prepared as follows : — At first they 
 should be washed in water slightly acidulated with hydro- 
 chloric acid until all effervescence, due to the action on lime 
 contained in the sponge, has ceased. They are then soaked 
 in sterilised water for an hour or two, and carefully cleaned. 
 Then they are placed in an antiseptic solution, e.g. carbolic, 
 for twenty-four hours. Afterwards they are squeezed and 
 thoroughly dried, and preserved dry in a closed bag until 
 wanted. Before the operation they should be soaked for 
 twenty-four hours in i in 20 carbolic lotion. After an 
 operation they are soaked in vater until all the blood is 
 dissolved out ; then placed in a covered dish containing 
 soda solution (one pound of soda to twelve sponges) for 
 twenty-four hours. Then they should be thoroughly washed 
 
 V 
 
ASEPSIS AND ANTISEPTICS. 
 
 249 
 
 \ \ 
 
 h 
 
 I 
 
 for hours in hot water, and afterwards in the antiseptic 
 lotion as above described. 
 
 Dressings, whether of wool or gauze, should be freshly 
 sterilised. Dry dressings from the manufactory, even if 
 impregnated with an antiseptic, may contain germs. The 
 antiseptic is active only in the liquid state. The sterilisation 
 may be carried out by means of a hot chamber, by boiling 
 in the soda-salt solution, or by soaking in an antiseptic 
 lotion. 
 
 Cleansing of the patient. — (a) In operations on the 
 external genitals, perineutn, and natural passages. — If 
 possible, the patient should take a bath the night before 
 the operation, the body being well scrubbed with soap 
 and warm water. It is well that the vagina should be 
 thoroughly douched with an antiseptic for several days 
 beforehand. Some pack the vagina each night with 
 iodoform gauze as well. A purgative should be given at 
 bed-time, and an enema in the morning. After the bowel 
 is moved, the nurse should thoroughly wash out the lower 
 gut with warm boracic lotion (i in 30). Before the opera- 
 tion, the bladder should be emptied. 
 
 If the external genitals are to be operated upon, as much 
 hair should be shaved from the labia majora and mons 
 veneris as is necessary to give a clear field of operation. 
 
 In such cases, some prefer to apply a boracic or carbolic 
 poultice to the vulvar region during the night before the 
 operation. This is really only necessary when there is a 
 very dirty surface, which may be difficult to clean thoroughly 
 otherwise* In the ordinary run of cases, it is sufficient, 
 after shaving off the hairs, to scrub the vulva, the perineal 
 and anal regions, the vagina, and the inner sides of the 
 thighs with warm water, turpentine, and soap. Then these 
 parts are thoroughly washed with an antiseptic solution, 
 e.g. I in 1000 of corrosive sublimate, or formalin. 
 
 Some operators always use the permanganate of potash 
 and oxalic acid solutions after washing in water. 
 
VN 
 
 250 
 
 OPERA TIVE MEASURES IN GENERAL. 
 
 During the operation the instruments may lie in sterilised 
 water or in weak antiseptic lotions. *' 
 
 The field of operation may be irrigated if necessary with 
 an antiseptic lotion by means of a douche, or it may simply 
 be swabbed from time to time. The lotion should not be 
 of such a nature as to hurt the instruments, ^.^•. formalin 
 lotion (i in 4000), solution of iodic hydrarg. (i in 5000), or 
 of hydronaphthol. Some use th2 simple boiled soda-salt 
 solution. It is quite non-irritating to wounds. 
 
 The interior of the uterus is cleansed by strong antiseptic 
 lotions introduced by swabs or by a double catheter. 
 
 After operations, the tract may be insufflated with iodo- 
 form or naphthalene powder, and a dressing of sterilised 
 antiseptic gauze or wool used. 
 
 if) In operations in ivhich the abdomifial cavity is opened. 
 
 a. Per vaginam. — The method already described will 
 suffice. In such a case it is well to pack the vagina with 
 iodoform gauze two or three nights before the operation, as 
 well as to douche the passage. Before the peritoneum is 
 opened into at the operation, the interior of the uterus 
 should be thoroughly cleansed. 
 
 i). Through the abdominal walls. — The vagina should be 
 douched with an antiseptic for several days before the opera- 
 tions. The evening before, a thorough cleansing of the body 
 with soap and warm water should be made. Afterwards the 
 nurse should wash the abdomen, mons veneris, and upper 
 aspect of the thighs with soap, turpentine, and water ; the 
 navel should be cleaned with chloroform or ether. It is a 
 good thing to shave the mons veneris at this stage. Some 
 prefer to do it when the patient is under chloroform. A 
 poultice of iodic hydrarg. (i in 4000), or of formalin solu- 
 tion (i in 1000), is then applied by some to the abdominal 
 wall, and not removed until the patient lies on the operating 
 table. Solutions in glycerin are best. They penetrate the 
 skin, and do not dry up. A purgative is given, and an enema 
 in the morning. The rectum is washed out with warm 
 
ASEPSIS AND ANTISEPTICS. 
 
 251 
 
 boric or formalin lotion, and the vagina is douched. The 
 urine is then drawn off if the patient cannot empty her 
 bladder. 
 
 In every case where the uterine cavity is likely to be 
 opened during the abdominal section, it is well to en- 
 deavour to disinfect it before the operation by a douche, 
 swabs, or by curetting. This is best done when under 
 the anaesthetic. When the patient is placed on the table, 
 the abdominal dressings are removed ; the skin is again 
 washed with turpentine anl water, and then bathed with 
 an antiseptic lotion. The abdominal surface is then sur- 
 rounded with sterilised Mackintosh sheetings, on which 
 sterilised towels, wrung out of a warm antiseptic lotion, are 
 placed. On these, instruments may be laid when necessary. 
 
 The instruments are taken from trays of weak antiseptic 
 lotion. Sterilised gauze and wool swabs may be washed in 
 the sterilised soda-salt solution, or in sterilised water alone. 
 They should be thrown away when saturated with blood. 
 
 If sponges are used, they should be washed in a series of 
 basins of antiseptic (not corrosive) and soda-salt solutions. 
 Before the swab or sponge is used, it should be taken from 
 the latter lotion, because it is quite non-irritating to raw 
 surfaces or to the peritoneum. 
 
 If it is necessary to wash out the abdominal cavity, the 
 sterilised soda-salt solution sufifices, though simple boiled 
 water may be tried. Some recommend weak boracic lotion, 
 sublimate lotion (i in 10,000), or iodic hydrarg. (i in 15,000) 
 in cases where pus or other germ-carrying material has 
 found its way into the peritoneum. Such antiseptic lotions 
 are of very little use. They are not strong enough to kill 
 all germs and spores, and they may damage the peritoneum 
 somewhat. 
 
 In all cases the cavity should be thoroughly dried before 
 closure. Strong antiseptics easily damage the peritoneum, 
 and so interfere with its action. Serous surfaces will better 
 digest infectious matter if the endothelium be normal. 
 
\\ 
 
 252 
 
 OPERATIVE measure:^ IN GENERAL. 
 
 In all abdominal sections this power of the peritoneum 
 should be remembered. The greatest danger of the local 
 overcoming of this power results from the presence of fluid, 
 e.g. blood, in which the germs may rapidly grow. The line 
 of the incision and the surrounding parts should be dusted 
 with iodoform or naphthalene powder, and covered with 
 sterilised antiseptic gauze pads, or with gauze pads contain- 
 ing wool. The pads should be held in position by a piece 
 of iodoform gauze, which is fastened to the abdominal wall 
 with collodion. Outside this, layers of sterilised antiseptic 
 cotton are placed, and the whole enveloped in a bandage, 
 or held in position by adhesive plaster. 
 
 Cleansing of the air and contents of the room. — In 
 the early days of antiseptics, great attention was directed to 
 the air itifection of wounds. Now it is recognised that it is 
 very much less to be feared as a source of danger than 
 infection by contact or by i?ftp/antation. 
 
 To reduce to a minimum the risk of air infection, opera- 
 tions should be done in rooms with smooth clean walls and 
 ceiling, with simple fittings and furniture. There should be 
 no hangings, mats, carpets, nor any unnecessary articles 
 which might collect dust. The dust is to be removed by 
 ventilation, and by washing the room and its contents 
 thoroughly. 
 
 Some operators like to burn stick-sulphur all night before 
 the operation, the doors and windows being firmly sealed. 
 In the early morning the smoke is removed by ventilation. 
 I think it is better to carry out this procedure the day 
 before, and to allow fresh air to remain in the room all 
 night. In this way there is less sulphurous acid gas in 
 the room during the operation. This is apt to irritate the 
 patient's throat, causing spasm of the larynx, thus rendering 
 the administration of the anaesthetic unpleasant. 
 
 A spray of formalin is now believed to be the best 
 bactericide to employ in the cleansing of a room. 
 
 It goes without saying that no source of decaying organic 
 
 ! \ 
 
ANTISEPTICS. 
 
 253 
 
 material should be near the room, e.g. a faulty drain pipe 
 or water-closet. 
 
 Various Chemical Antiseptics. — ]'. Those used in 
 Solution. II. Those used in Solid Form. 
 
 I. Those used in solution. — Corrosive sublimate. — This 
 is a valuable antiseptic. It must be remembered that it is 
 not active when dry. Therefore, germs and spores may lie 
 in or on dressings containing it, without being destroyed. 
 In strengths which can ^ be used without great risk of 
 absorption, its solutions vary greatly in their destructive 
 action on germs and spores. It is important to bear this 
 in mind. Some think that mere contact with a i in looo 
 solution is sufficient to destroy all organisms. This is not 
 so. Some will withstand its action for hours or for a day. 
 Zimmermann found that pieces of flesh soaked for i.ve 
 minutes in this solution were not with certainty sterilised, 
 though there is no doubt that the germs that are not 
 destroyed are weakened in activity. For this reason, it has 
 been recently recommended that at the end of an operation 
 the wound (not peritoneal) should be washed out with a 
 solution of the strength of i in 500. 
 
 With corrosive solutions, especially if strong, there is 
 danger of absorption by the system, and consequently of 
 toxic symptoms. 
 
 The risk of this may be diminished if, after the sublimate 
 is used, the wound be washed out with a \ per cent, steril- 
 ised salt solution. 
 
 A pure corrosive solution should not be used, because it 
 forms with albumin insoluble and inactive albuminate of 
 mercury, its power in this way being weakened. This is 
 especially marked when there is much fluid, e.g. leucorrhaa, 
 cancerous discharge, blood. 
 
 To the corrosive solution should be added a little tartaric 
 acid, in order to prevent the formation of the albuminate. 
 
u 
 
 254 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 A I per cent, or i per cent, solution of tartaric acid should ' 
 be used in making up a i in 1000 corrosive solution. 
 Common salt has the same action. Tartaric acid is best 
 added before using the corrosive. If it be added to a strong 
 solution, it changes the mercuric salt to calomel in two or 
 three weeks. 
 
 The objections to the use of mercury are that it is toxic 
 if absorbed to any extent into the system. It corrodes 
 metallic instruments, and loses its strength somewhat when 
 they are immersed in it, because the mercury tends to be 
 deposited on them. Sponges, also, are hurt by it. Glass 
 and porcelain are not injured by it. 
 
 Biniodide of mercury or mercuric iodide. — This salt is 
 believed to be very valuable. It does not form insoluble 
 compounds with albumin, and it does not corrode metals 
 much. It is used in strengths of i in 1000, i in 2000, etc. 
 
 Iodic hydrarg. — (Mercuric -potassio, mercuric iodide.) 
 This is a most valuable antiseptic. It is a soluble form 
 of mercuric iodide. It does not form an albuminate with 
 albumin. It is not irritating nor so toxic as sublimate when 
 it is absorbed by the system. It is rapidly eliminated by 
 the kidneys. It is said to have twice the germicidal strength 
 of corrosive, and it is safer to use in the peritoneal cavity. 
 
 Formalin, formaldehyde, formol, formic aldehyde. — This 
 substance is prepared by passing a mixture of air and vapour 
 of methyl alcohol over incandescent platinum. The liquid 
 which condenses is formic aldehyde dissolved in methyl 
 alcohol. The commercial solution is usually 40 per cent, in 
 strength. At an ordinary temperature formic aldehyde is 
 a colourless gas with an irritating odour. At a temperature 
 of 20° C. it changes to a polymeric form, known as para- 
 formaldehyde, a white substance, soluble in water and 
 alcohol. Formalin is in its gaseous form the best and most 
 convenient germicide which can be used for the purification 
 of rooms, furniture, books, etc. Its solution is probably 
 more quickly destructive to organisms and their spores than 
 
ANTISEPTICS. 
 
 255 
 
 corrosive sublimate. Unlike the latter, it is not toxic 
 as a result of absorption, save in very strong solutions 
 administered in large quantities. In ordinary solutions it 
 is, moreover, but slighdy injurious to tissues. Its vapour 
 diffuses quickly, and can penetrate the skin and its glands. 
 It is non-corrosive, and does not hurt instruments. 
 
 It may be used in the strengths of i in 500, i in 1000, 
 etc. If eight drops of the ordinary 40 per cent, formalin 
 solution be added to a pint (20 oz.) of water, the strength 
 of the latter is i in 3000. 
 
 The pure solution may be applied to dirty sores, ulcers, 
 chancres, etc. Mixed with an equal part of water the 
 uterus may be swabbed out after a curetting. The most 
 resistant microbes are killed by an hour's contact with a 
 I in 1000 solution. 
 
 The action of formalin can be stopped with ammonia, 
 which forms with it a harmless compound. 
 
 HydrotiaphthoL — This material is non-poisonous, non- 
 irritating, non-corroding, and a strong antiseptic. It may 
 be used in solutions of i in 1000, i in 2000, etc. Weak- 
 solutions may be used to flush out the peritoneum. 
 
 ^-naphthol. — This may be used in watery solution. The 
 saturated solution is only 2 per cent, in strength. Boracic 
 acid helps its solubility. 
 
 Carbolic acid. — The ordinary i in 20 solution is a good 
 antiseptic, save in the case of the spore-bearing bacilli. 
 But contact for several hours is necessary in the case of 
 some. It is in favour of carbolic lotions that they do not 
 nurt instruments. 
 
 Carbolic acid is easily absorbed into the system by means 
 of raw surfaces, and may cause toxic symptoms. It also 
 acts unpleasantly on the skin of the operator. This sub- 
 stance is, therefore, not so serviceable as some other anti- 
 septics. Supplies of ligature may be kept in solutions of it, 
 to be ready for use. 
 
 Lysol. — This is an alkaline fluid, derived from the saponi- 
 
 X 
 
 ri i 
 
 §b4 
 
256 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 fication of cresols. It is incompatible with acids. It is 
 said to be a stronger germicide than carbolic acid, and less 
 poisonous. It is used in a strength of i in loo as a douche, 
 for washing the hands and for instruments. 
 
 Boracic lotion (30 in 1000) and salicylic lotion (i in 1000) 
 are non-irritating, and may be used for instruments or for 
 washing out the rectum or bladder. 
 
 Thymol. — This substance is a good antiseptic. As i part 
 is soluble only in 1500 of water, glycerin should be added 
 if stronger solutions are desired. Ordinary strengths em- 
 ployed are i in 1000 to i in 2000. 
 
 lodoformised or bichloride collodium should be used when 
 it is desired to fasten dressings to the skin around the 
 wound. 
 
 Ferripyrin. — This substance is highly recommended by 
 Witkowski as an astringent, anaesthetic, antiseptic, without 
 irritant action. A 16 per cent, watery solution can be 
 applied to a bleeding or diseased surface, with a swab or 
 dressed sound. A i| per cent, solution can be used for 
 irrigation of wounds or on plugs. Solutions varying in 
 strength from i to 16 per cent, can be used for bladder 
 bleedings. In stomach or bowel haemorrhage it can be 
 administered by the mouth. 
 
 II. Used in solid form. — {a) Iodoform. — This substance 
 is used as powder, in pencils for introduction into the 
 uterus, as pessaries for the vagina, and in gauze. It 
 may also be used in a solution of alcohol and ether, as 
 follows: — Iodoform, 10 parts; alcohol, 80; ether, 20. It 
 is a valuable antiseptic, but it becomes active only when 
 fermentation has begun. By this action the iodoform is 
 decomposed, and the products are said to unite with the 
 ptomaines and toxalbumins, and so to prevent the develop- 
 ment of the germs. 
 
 Germs and spores may live among iodoform without 
 being affected. They cannot, however, continue septic 
 processes where the iodoform is abundant. 
 
 ! \ 
 
ANTISEPTICS. 
 
 «57 
 
 It is, probably, according to Kocher, the most active 
 agent in combating decomposition. It really serves no 
 purpose when placed on wounds which heal aseptically, 
 but it is of great value in those where sepsis usually 
 occurs. 
 
 Toxic effects are produced by its absorption, e.g. rise of 
 temperature, frequent pulse, mental dulness, and there may 
 be delirium, collapse, and coma. 
 
 Iodoform gauze may be made as follows : — Pure gauze 
 is sterilised by boiling, and then soaked in the following 
 solution : — 
 
 Iodoform . . 50 grms. 
 Glycerin . . 100 „ 
 
 Ether . . . 700 „ 
 
 The gauze is then passed through a drying roller-machine, 
 and then dried at a temperature of 30° C. It can then be 
 preserved in air-tight cases. 
 
 Tannin may also be added to give the gauze an astrin- 
 gent haemostatic action. 
 
 Sterilisation of iodoform gauze can be carried out by 
 boiling or by hot air. 
 
 Corrosive sublimate. — Sublimated gauze and wool may 
 be made by boiling the pure material in sodium carbonate 
 solution (20 in 1000), then in corrosive solution (i in 1000). 
 Afterwards it is dried. Dry gauze or wool is inert as regards 
 germs and spores. All articles, therefore, from manufac- 
 tories should be sterilised before being used. 
 
 Salicylic acid is also used in powder or in gauze. 
 
 Naphthalene. — This is a cheaper material than iodoform, 
 and may be used as a powder for sprinkling on raw sur- 
 faces or in abscess cavities. It may be used, combined 
 in equal parts, with iodoform, or it may be mixed with 
 a little calamine powder in order that it may be less 
 sticky. 
 
 Ferripyrin can be used in powdered form. 
 17 
 
 
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 Sciences 
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 i3 WEST MAIN STREET 
 
 WEBSTER, N.Y. 14580 
 
 (716) 872-4503 
 
 
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258 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 / 
 
 Apparatus, Ligatures, Instruments, etc. 
 
 The operating table should be simply constructed. It 
 should be made of metal, e.g. galvanised iron, so as to be 
 easily cleansed. 
 
 For operations on or by way of the natural passages, the 
 patient should be placed in the lithotomy position, her 
 buttocks projecting slightly over the end of the table. The 
 legs may be held up by assistants, but it is more convenient 
 to employ leg-rests fastened to the end of the table, or a 
 special leg-holder, which is attached to the knees, and is 
 held by a strap passed around the table. 
 
 A simple arrangement may be adopted by means of a 
 walking-stick and a long bandage. The stick is placed in 
 the flexion of the knees, fastened to them by the bandage, 
 which IS also passed around the neck of the patient or 
 under the table. The feet and legs of the patient should 
 be covered with clean stockings and sterilised linen 
 coverings. 
 
 The patient's hips should rest on a piece of rubber cloth, 
 or, better, on a circular rubber pad with a raised rim on a 
 projection, which extends over the table-end into a collecting 
 basin. 
 
 In private practice these operations may be performed on 
 a convenient table, but sometimes it is necessary to place 
 the patient on the edge of the bed. In the latter case, the 
 knees may be held up conveniently by means of the walking- 
 stick and bandage. 
 
 Attached to the operating table may be stands to hold 
 dishes of instruments and swabs. These may be placed 
 on chairs, or may be given to the operator by assistants. 
 
 A good window-light should shine on the patient's 
 buttocks. The operator sits on a stool facing the end of 
 the table. 
 
 For operations in which the incision is made in or through 
 the abdominal wall, the patient may be placed on a high 
 
 \ 
 
 t 
 
 S 
 
 \ 
 
 a 
 F 
 
 ^ 
 
 r 
 
 f\ 
 
 \, 
 
APPARATUS, INSTRUMENTS, ETC. 
 
 259 
 
 table covered with a blanket and sterilised rubber cloths. 
 The patient lies on her back, wearing clean stockings and 
 a flannel night-dress. The latter is well drawn up under 
 her chest. Hot -water bottles are placed on each side of her 
 legs. The latter are covered with a sterilised cover, which 
 is securely fastened around the ta' ie. The patient's 
 arms should be fastened to the table or pinned to the 
 pillow. 
 
 The operator stands on one side, usually the right, and 
 his assistant on the other. 
 
 A good window-light should shine on the abdomen of 
 the patient, either from above or opposite the end of the 
 table. 
 
 An improvement upon the flat table is an arrangement by 
 which, during abdominal sections, the lower limbs may be 
 somewhat elevated. This is the position which is most 
 favourable to the administration of anaesthetics, and is most 
 apt to benefit those cases in which the cerebral circulation 
 tends to become dangerously disturbed. 
 
 Some operators prefer to operate standing or sitting at 
 the end of the table between the patient's legs, which are 
 raised and held by supports. Frau Horn's table is the 
 best-known one, and is used by Martin of Berlin. 
 
 In certain cases the Trendelenburg position may be 
 employed. To place the patient aright, the lower end of 
 the ordinary flat table may be raised, or a specially con- 
 structed apparatus may be employed to raise the patient's 
 pelvis to a higher level than that occupied by her head. 
 
 For use in abdominal sections, a good electric lamp with 
 a reflector is often valuabi.^ in illuminating deep parts of the 
 pelvis or abdomen when the window-light is not good. 
 
 The operating room must be well warmed (25° to 30° C). 
 The air should be moist, in order that exposed peritoneum 
 may not suffer. 
 
 Needles. — For passing ligatures through the pedicle in 
 the removal of tumours by abdominal sections, in vaginal 
 
V 
 
 26o 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 colpotomy or in vaginal extirpation of the uterus, the best 
 needle is one attached to a long handle. It should be full 
 curved, and the point should not be sharp. 
 Different shapes are used. The needle may 
 be in line with the handle, at right angles to 
 it, or at an obtuse angle. The latter forms 
 may be obtained with the needle attached on 
 the right or left side of the handle. Some 
 operators, however, prefer to use ordinary 
 full-curved needles with needle-holders in 
 these operations. 
 
 For other purposes, e.g. the repair of the 
 perineum, amputation of the cervix, etc., it 
 is best to use needles with a needle-holder. 
 The most convenient needles are the full- 
 curved ones, such as are so largely em- 
 ployed by Martin of Berlin. The curve 
 allows them to be passed easily when work- 
 ing in a deep wouncf. Different sizes may 
 be obtained, from the large ones used in 
 suturing the abdominal walls after section, to 
 the small ones used in suturing a wounded 
 intestine. In passing these needles the hand 
 must turn well, because of the curve they 
 have. The simplest and best needle-holder 
 is Martin's. It should have a separable 
 lock. 
 
 Sutures. — Silver wire has been used in 
 gynecology, but it may safely be said that 
 it is practically unnecessary. 
 
 Silk is largely used in various sizes, twisted 
 
 or plaited. Its chief use is in securing the 
 
 pedicle of ovarian and uterine tumours, in 
 
 Fig. 73.— Pedicle suturing the abdominal walls after section, 
 
 "^^ ^' and in extirpation of the uterus. The 
 
 thickest silk is generally known as "pedicle silk." It is 
 
APPARATUS, INSTRUMENTS, ETC. 
 
 261 
 
 twisted. For the abdominal walls plaited Chinese silk is 
 largely employed (Nos. 7 and 8). 
 
 The value of silk is its strength and durability. Its resist- 
 ance to absorption is the great objection to it. It is apt 
 to set up irritation, and may lead to the formation of a 
 sinus. Being very porous, it may easily carry germs. For 
 these reasons some operators never use it where sutures 
 are buried, e.g. in the abdominal cavity or in the bottom of 
 deep wounds. Martin, for example, uses it practically only 
 for the closure of the* ab- 
 dominal incision, catgut being 
 employed for all other pur- 
 poses. 
 
 Catgiit. — There is no doubt 
 that this is by far the most 
 widely used and most service- 
 able material for most ligiitures 
 and sutures. It may be ob- 
 tained in four sizes, from No. o, 
 used in suturing a wounded 
 intestine, to No. 4, used where 
 important vessels are to be 
 secured. No. 4 is used by 
 Martin in abdominal operations, where most other operators 
 use silk. 
 
 The great advantage of catgut is that it lasts long 
 enough for purposes of healing, and that it is then 
 absorbed by the tissues when in position. Its durability 
 depends upon its size and nature. The range of juniper 
 gut is from one to three weeks. Chromic gut is more 
 durable. 
 
 It must be noted that catgut may easily rot if kept too 
 long, or if not carefully prepared or kept. It tends to fray 
 out if at all injured, and the knot may slip if not care- 
 fully tied. The knot should be triple and not double. 
 
 Different preparations of catgut are employed. The 
 
 Fig. 74. — Martin's full-curved 
 needles. 
 
V, 
 
 262 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 well-known carbolised gut should not be used. It is not 
 
 so reliable as the fol- 
 lowing forms : — 
 
 Chromic catgut. — 
 This is prepared by 
 taking 5 parts of the 
 best gut, on the stretch, 
 soaking it in a mixture 
 of chromic add ( I part) 
 and distilled water (12 
 parts), then, after wip- 
 ing it in a cloth, placing 
 it for twelve hours in 
 100 pa.ts of sulphurous 
 acid. It is then dried. 
 Jutiiper catgut. — 
 The best gut is soaked 
 for five or six hours in 
 corrosive solution (i in 
 1000). It is then placed 
 in the oil of juniper 
 wood for eight or more 
 days, and afterwards 
 preserved in alcohol, 
 to which a tenth of the 
 essence of juniper is 
 added. Some recom- 
 mend sterilising the gut 
 for three or four hours 
 after it has soaked in 
 the corrosive solution. 
 However catgut is 
 prepared, it is perhaps 
 
 well at first to wash it in ether or benzene, in order to 
 
 remove any grease that may be on the surface. The chromic 
 
 gut is the longest to disappear. 
 
 Fig. 75. — Martin's needle-holder. 
 
 l\ 
 
APPARATUS, INSTRUMENTS, ETC. 
 
 263 
 
 Before being used in operations the gut must be 
 thoroughly sterilised. 
 
 Silktvorm gut. — This is impermeable and non-absorbent, 
 not so strong as silver, and less flexible. It may be used 
 where silver would be used. Some use it in cases where 
 silk might be employed. Its knot is apt to give. It should 
 be soaked in an antiseptic before use. It is easily cleaned. 
 
 Horse-hair is seldom use(^, and is not necessary. It is 
 used by some to bring skin surfaces of an abdominal wound 
 together. Catgut, however, or silk-worm gut, serves well for 
 this. 
 
 Linen sutures. — Gubaroff highly recommends linen 
 sutures as having none of the disadvantages of silk or 
 silk-worm gut and being inexpensive. He prepares them 
 as follows : — 
 
 The threads are boiled in a soda solution, to remove the 
 fat, and afterwards are washed in cold water. They are 
 then boiled for six minutes, and next placed in absolute 
 alcohol for six hours, when this process is again repeated. 
 From the alcohol they are placed in a warm room to dry, 
 and are then rolled on glass spools. These are placed for 
 twenty-four hours in a 30 per cent, solution of celloidin 
 in equal parts of alcohol and ether, to which is added i per 
 cent, of sterilised oleum ricini. The sutures are then rolled 
 on a wooden frame to dry, and the excess of celloidin is 
 removed by the fingers or with clean paper. They are kept 
 in a closed glass vessel, and before use are twice boiled in a 
 I in 1000 solution of corrosive sublimate. 
 
 Different forms of sutures. — Separate sutures. — These 
 may be passed in a single row, or there may be two or three 
 rows, according to the depth of the wound. In such cases 
 the ligatures are tied on the skin. 
 
 Separate tiers of sutures may be used in order to close 
 the wound thoroughly from the bottom upwards. The 
 buried sutures should be of catgut. 
 
 In the closure of wounds the great desideratum is, if 
 
 
 !i 1 
 
i64 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 possible, to bring the raw surfaces together accurately, 
 without leaving spaces between them in which serum or 
 clot can accumulate. The raw surfaces should be aseptic, 
 they should not be injured by chemical reagents, nor by 
 mechanical mear , e.g. squeezikig, compression. Healthy 
 tissue is not a good soil for bacteria. It has a resisting 
 influence against them. Blood clot or serum lying in a 
 wound, on the other hand, is a spbndic' soil. 
 
 When in any case we cannot ensure this exact closure 
 of a wound, it is best to establish free drainage, and to 
 dress legularly with antiseptics. Separate sutures are not so 
 reliable in thoroughly closing wounds of some depth as the 
 continuous suture. 
 
 Continuous catgut suture. — This suture is most valuable. 
 It serves not only to bring wounded surfaces together ; but 
 it is also a splendid means of checking haemorrhage. The 
 gut is passed continuously by means of a curved needle, the 
 full-curved form being best for difficult cases. 
 
 A single row of turns of the suture may be sufficient in 
 the case of a small wound. These may pass through skin 
 and as much subjacent tissue as is wounded. In beginning 
 the suturing it is best first to close the upper skin angle of 
 the wound by tying a knot. On the short end of the suture 
 a pair of forceps is fastened, and held tight by an assistant. 
 In this way a point d'appui is afforded for the suture. The 
 wound is then closed as the needle is passed through the 
 skin surface, a quarter of an inch or more from the edge. 
 After each passage of the needle the suture is pulled tight, 
 and is held out by the left hand of the operator, or by an 
 assistant. 
 
 Some prefer to pass the needle under the loop made 
 immediately above, before the latter is drawn tightly. To 
 tie the knot it is best to follow Martin's procedure. When 
 the needle is to be passed for the last time there should be 
 an end to the suture, of some length, projecting from the 
 needle. The end is held on the side of entrance, while the 
 
APPARATUS, INSTRUMENTS, ETC. 
 
 265 
 
 needle is passed completely. With the latter are two pieces 
 of the gut. They are pulled tightly, and then tied to the 
 single end on the other side of the wound. In making 
 a knot the first turn should be double and the rest should 
 be as in an ordinary reef-knot. Besides this, it is well to 
 add a third part to the knot. 
 
 When a wide or deep wound is to be closed, the same 
 method is employed in a series of stages, from the bottom 
 of the wound to the skin-surface. The upper angle of the 
 skin portion of the wound is closed as described. The 
 
 A 
 
 f 
 
 Fig. 76.— Diagrams to illustrate method of using the 
 continuous catgut suture. 
 
 1. Surface view ; 2. Sectional view. 
 
 needle is then entered deeply, passing from side to side, 
 bringing the lowest portions of the raw surface together. 
 The assistant keeps the suture constantly tight. A second 
 stage is now passed with the same suture, bringing together 
 the wounded surfaces just above the level of the first stage. 
 Thiru and fourth stages may be added if necessary. Finally 
 the skin is closed. 
 
 In closing a deep wound a little caution is needed not to 
 allow little cavities to remain, nor to cut with the needle 
 previously passed sutures. If a suture is too short for the 
 
 !>ij| 
 
 \ n 
 
 
266 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 I 
 
 complete closure, it may be tied, and another one started, 
 beginning by a knot near where the other stopped. The 
 whole process must be carried out with strict regard to 
 asepsis. 
 
 Ligature en masse. — It is important that the different 
 methods employed to control bleeding from the pedicle 
 in case of the removal of the appendages, of tumours, etc., 
 should be thoroughly known. 
 
 When the pedicle is not large, the Staffordshire knot of 
 Lawson Tait, Bantock's knot, or several interlacing ligatures, 
 
 I. 2. 
 
 Fig. 77. — Ligatures applied to a pedicle. 
 I. Staffordshire knot ; 3. Bantock's knot. 
 
 may be used. For each of these the ligature is passed 
 through the pedicle by means of a pedicle needle. A part 
 is chosen which has no large vessel. The needle is then 
 withdrawn. 
 
 Staffordshire knot. — The loop is thrown over the mass to 
 be removed, until it rests on the free ends. One of these is 
 then drawn through this loop so as to rest on it. Both 
 ends are drawn tight so as to constrict the pedicle. They 
 are then tied, the first part of the knot having a double turn. 
 
 Bantock knot. — When the needle is withdrawn, one of 
 the free ends is carried around the pedicle, passed through 
 the loop and tied to the other free end on the other side of 
 the pedicle. 
 
 W 
 
APPARATUS, INSTRUMENTS, ETC. 
 
 267 
 
 Interlacing ligatures. — When the needle is withdrawn the 
 loop is cut, and the two parts are interlaced. One part 
 is tied on one side of the pedicle, the other on the other. 
 In the case of a larger pedicle it is best to employ more than 
 two interlacing structures. For this purpose the needle must 
 
 Fig. 78.— Double and triple interlacing sutures, 
 
 pierce the pedicle more than once. A simple method of 
 carrying this out may be seen in Fig. 79. 
 
 Elastic ligature. — This is practically only applied to the 
 pedicle in case of removal of fibroids, in abdominal 
 hysterectomy, and Caesarean section. ft may be used 
 
 Fig. 79. — Method of passing interlacing sutures, 
 
 temporarily, or it may be left in position for days, e.g. in 
 extraperitoneal treatment of the stump in abdominal 
 hysterectomy. 
 
 The best round, strong rubber band should be used. 
 Different methods are employed for holding the ends after 
 the pedicle is embraced. Both ends may be held in a small 
 
 % 
 
 ' II 
 
■II 
 
 268 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 
 grooved piece of metal or vulcanite. They may be tied 
 with silk, or may be held in a strong pair of forceps close 
 to the pedicle. Pozzi uses a special instrument to tighten 
 and hold the ends. 
 
 Forceps, — Ordinary artery forceps are greatly used in 
 various operations. Greig Smith's, Spencer Wells', and 
 Kocher's forceps, with separable locks, are very convenient 
 forms. 
 
 Of great value for forcipressure in different abdominal 
 operations are the medium-sized and long forceps of such 
 patterns as Keith's. The Pdan-Richelot forceps are of use 
 in controlling the broad ligaments in vaginal extirpation. 
 Other special forms of forceps will be referred to in con- 
 nection with the operations in which they are used. 
 
 Drainage. — Drainage of wounds, not connected with the 
 
 peritoneum, may 
 be carried out by 
 means of rubber 
 tubes, whose sides 
 are perforated. An- 
 Sometimes glass 
 
 Fig. 8o. — Glass drainage-tube. 
 
 tiseptic gauze may also be employed 
 tubes may be used. 
 
 When the peritoneal cavity is to be drained through the 
 abdominal opening, various plans may be tried. Glass 
 tubes, with small perforations in the sides, may be used. 
 Generally they are passed into the pouch of Douglas 
 through the abdominal wound near the lower angle. When 
 the wound is closed all the sutures are tied except the one 
 immediately above the tube. It is fastened when the tube 
 is withdrawn after six, twelve, twenty-four, or more hours as 
 the case may be. While the tube is in position, any fluid 
 that gathers in it may be withdrawn from time to time by 
 means of a syringe and rubber tubing. By some, antiseptic 
 gauze or lamp-wick is used along witn the tube to give 
 constant capillary drainage. 
 
 In certain cases of abdominal section a large tampon has 
 
 \\ 
 
APPARATUS, INSTRUMENTS, ETC. 
 
 269 
 
 been used by some operators. It is haemostatic, antiseptic, 
 and allows of drainage. Mikulicz's plan is to make a long 
 sac of iodoform gauze, which is placed in the part of the 
 cavity to be plugged. To the bottom of the sac a long 
 piece of string is previously fastened. It is brought out 
 through the opening of the bag. The sac is then packed 
 with a series of strips of gauze. The order in which the 
 strips are placed in the sac should be marked by strips of 
 
 Fig. 81. — Mikulicz's plug. 
 
 coloured yari. attached to their outer ends. They should 
 be removed in tne reverse order of their introduction. It 
 i:> an advantage also to place a drainage-tube in the very 
 centre of the mass. 
 
 All excess of iodoform should be removed from the gauze 
 beforehand by beating it, in order to lessen the danger of 
 absorption. 
 
 The tampon is left in position, according to the amount 
 of oozing. It is impossible to lay down exact rules. 
 Mikulicz states that the gauze packing may be removed 
 
270 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 after forty-eight hours, and the sac later. Fresh gauze may 
 be introduced. Sometimes it may be necessary to drain the 
 peritoneum through the vaginal fornix. This may be done 
 by a x-shaped rubber tube. Iodoform gauze may be 
 placed in the vagina, which may be douched from time 
 to time. 
 
 Iodoform gauze alone may be used for this purpose. It 
 should be frequently changed, and drainage kept up for 
 several days, according to the nature of the case. 
 
 Abdominal Section in General. 
 
 Preparation of the patient. — Prior to the operation, her 
 general condition should be made as healthy and quiet as 
 possible. A very careful examination of the various systems 
 must be made. Where the kidneys do not work freely, as 
 may be the case when there is a large tumour, diuretics 
 should be prescribed. Nourishing, easily digested food 
 should be given, and the bowels should be kept open 
 with daily regularity. If the patient be suffering from any 
 condition which might interfere with the success of the 
 case, e.^s^. bronchitis, the operation should be postponed, 
 unless urgent, until the patient is better. 
 
 For a week or ten days before operation the patient 
 should rest, lying down for a few hours each day. The 
 last two or three days she should spend entirely in bed. A 
 record should be kept of the temperature and pulse-rate 
 during this period. 
 
 A daily antiseptic vaginal douche should be administered. 
 If, in the operation, the uterus is likely to be partly or wholly 
 removed, an iodoform gauze plug may be placed in the 
 vagina after each douche ; and on the two days before the 
 operation the douche may be given twice per diem. 
 
 In the evening of the last day she should have a thorough 
 washing in warm water. The abdon.en and pudenda should 
 be washed with turpentine, warm water, and soft soap. 
 
ABDOMINAL SECTION, 
 
 271 
 
 Then a cloth wrung out of an antiseptic lotion, e.g. formalin 
 (i in 1000), should be placed on the abdomen and enveloped 
 m a waterproof cover. A dose of opening medicine should 
 be given. 
 
 Early the next morning an enema should be administered, 
 and when the bowels move, the lower gut should be washed 
 out with warm boracic lotion. The vagina should also be 
 douched with an antiseptic lotion. 
 
 The operation should take place in the morning. No 
 breakfast, save a cup of weak tea or water, which may be 
 given early. It is said that if fluids be freely administered 
 there is less danger of troublesome thirst after the operation. 
 In any case, nothing solid is allowed, nor any" milk which 
 forms a curd. 
 
 Some operators advise that half an hour before the opera- 
 tion the patient should get a dose of brandy by the mouth, 
 and a hypodermic injection of morphine and atropine. 
 
 She should wear clean stockings, a clean under-shirt, and 
 a clean night-gown. Just before the anaesthetic is adminis- 
 tered the nurse empties the bladder with a catheter. In 
 hospital the patient should then be carried to a room next 
 the operation rcom, where she is anaesthetised. In private 
 the anaesthetic may be given while she is still in bed. 
 
 In the meantime the operating room has been made ready 
 for her reception, the operator, his assistants, and nurses 
 have made their hands and arms aseptic. If the table to 
 be used is the ordinary flat one, it is covered with a clean 
 blanket, on which is placed a waterproof cover and a clean 
 sheet. On the top should be placed a circular rubber pad 
 with a flap reaching over the side of the table. 
 
 The patient is now placed on the table, her buttocks 
 resting on the pad. The clothes are then drawn up under 
 her arms and a clean blanket placed over her legs. On each 
 side of her legs should be placed a bottle of hot water, 
 and over the blanket a clean sheet should be placed, which 
 should be fastened around the table. Her arms should 
 
w 
 
 z^- 
 
 vt% 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 
 
 be tied to the table. The abdominal poultice is removed 
 and the hair of the mons ven^/is shaved ; the abdomen is 
 carefully scrubbed with turpentine, water, and green soap, the 
 navel being thoroughly cleaned with chloroform, and, after- 
 wards, washed with potassium permanganate and oxalic acid 
 solutions. The surface is then soaked with a strong anti- 
 septic lotion, e.g. formalin or corrosive, i in 2000. It is 
 then washed with sterilised salt solution. 
 
 Sterilised thin waterproof cloths are now placed above 
 and below the abdominal region, and on each side of it. 
 These are covered by sterilised towels wrung out of a weak 
 antiseptic solution, a sheet of sterilised gauze being placed 
 over the abdomen. 
 
 The operator stands on one side of the table, usually the 
 right, and his chief assistant on the other. Another assistant, 
 or nurse, looks after the instruments, which have been laid 
 out in flat dishes containing sterilised salt solution or a 
 weak solution of boracic acid. A nurse attend to the swabs, 
 sponges, and lotions that may be used during the operation. 
 The swabs, sponges, and instruments are carefully counted. 
 A number of artery forceps, a bistoury, and a pair of scissors 
 are placed on the antiseptic towel covering the patient's 
 legs. A swab is given to the chief assistant before the 
 operator makes his incision. 
 
 Opening into the peritoneum. — Most operators select 
 the middle line between the pubes and umbilicus. This 
 incision is accompanied with least injury, for no muscle, 
 large nerves, or important vessels are divided. Sometimes 
 an unclosed umbilical vein may be cut, or one or more 
 veins in the extraperitoneal fat. This incision may be em- 
 ployed for most purposes, as it affords equal access to both 
 sides of the pelvis. This is especially valuable in cases where 
 beforehand it is suspected that a bilateral operation may be 
 necessary. If, when this incision is made, it is not sufificient 
 even when lengthened, another incision may be made at 
 right angles to it, in order to give more access to the side. 
 
 I \ 
 
ABDOMINAL SECTION. 
 
 273 
 
 
 The chief objection to the mesial incision is that the 
 resulting cicatrix is not apt to be as strong as that following 
 incision elsewhere. 
 
 Some operators, therefore, always make the incision to 
 one side of the middle line. If this be vertical, it should 
 divide the inner part of the rectus. Vertical incisions in 
 the outer part of the rectus or outside this muscle, if of any 
 length, are not so desirable, because the nerves which supply 
 the muscle are divided. In the upper region of the abdomen 
 this is apt to be more serious than m the lower portion. If 
 lateral 'ncisions, therefore, are to be made, the large nerves 
 will be protected if the abdominal wall be cut in an oblique 
 or transverse line. 
 
 Transverse division of the rectus is not to be feared. 
 Strong tendinous union takes place after suture, and the 
 contraction of the muscle is not interfered with. 
 
 The length of the incision to be made depends on the 
 nature of the case. It is a common practice to make a 
 small one at first, about 3 in. in length, and afterwards to 
 enlarge it if necessary. 
 
 The incision is made as follows : — Let us suppose that 
 it is a mesial one. The skin and superficial fascia with 
 fat are divided. Bleeding points are caught with forceps, 
 because all bleeding should be checked before the peri- 
 toneum is opened. Large vessels may be tied with catgut. 
 Most of the bleeding points are, however, checked by the 
 temporary application of the forceps. The junction of 
 the sheaths of the recti (linea alba) is divided, then the 
 transversalis fascia which is transversely striated. Under 
 this lies the extraperitoneal fat. It varies in thickness. 
 Usually it is scanty when the superficial fat is not abundant. 
 It should be caught up on each side of the middle line 
 by artery forceps held by the operator and his assistant. 
 Deeper and deeper portions should be caught and divided, 
 until at last the peritoneum is incised. These precautions 
 are necessary in order that no damage be done to the bowels 
 18 
 
 jS I 
 
■^ 
 
 274 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 or omentum. The obliterated urachus may be found in 
 the middle line, but it can be pushed aside. It may some- 
 times be unobliterated for a distance, and may contain 
 calculous deposits, or may communicate with the bladder. 
 
 Ordinarily when the slightest hole is made in the peri- 
 toneum the bowels fall away from the surface, owing to the 
 inrush of air. When, however, they are adherent to the 
 parietal peritoneum, there is great risk of opening into 
 them. In these cases, if the adhesions cannot be separated, 
 it is necessary to close the opening in the abdominal wall, 
 and it is justifiable to endeavour to make an opening at 
 another part. If the bowel be cut into, it should be closed 
 by catgut sutures (No. o or No. i), passed through both 
 the serous and muscular coats, the edges being turned in 
 towards the lumen of the bowel. 
 
 Sometimes it is difficult to recognise the peritoneum. It 
 may be very thin and the extraperitoneal fat may be mis- 
 taken for the omentum. When there is much ascites, it 
 may project and be mistaken for a thin cyst wall. When 
 there art many adhesions below, it may be mistaken for the 
 same strui 're. If it be very much thickened by inflamma- 
 tion, it may be difficult to distinguish. 
 
 As a rule the omentum is above the umbilicus. If below, 
 it can easily be pushed aside unless adherent. If ad- 
 herent it should be carefully separated from the abdominal 
 wall, and pushed up or to one or other side. Bleeding 
 vessels in it may be ligatured, or portions may be sutured 
 en masse. Sometimes it may be necessary to cut through 
 the omentum, tying the vessels. 
 
 Bowel adhesions, if recent, may be broken through by 
 means of the finger or swabs. If they are of any length, 
 they may be tied in two places, and divided. Sometimes 
 they are short and strong, and cannot be touched. 
 
 If the peritoneum be successfully opened, a finger should 
 be passed in, the bowel pushed aside, while the rest of the 
 peritoneum is cut with a pair of scissors the full length of 
 
 
 f \ 
 
ABDOMINAL SECTION. 
 
 m% 
 
 the wound. Two or three fingers are then introduced, in 
 order that the diseased part may be palpated. If these are 
 not sufficient, the whole hand should be introduced, the 
 opening being made large enough. In cases where the 
 nature of the internal condition is uncertain, e.g. intestinal 
 obstruction, rupture of a tumour, an ectopic gestation sac, 
 etc., it is best to make a large opening at once, 4 or 
 5 in. in length, in order that there may be no trouble in 
 examining the viscera. 
 
 Before the condition can be treated it may be necessary 
 to carry the incision above the umbilicus. In so doing it is 
 best not to divide the navel, but to cut to one side of it. 
 Often, also, the incision is extended downwards nearly to 
 the symphysis. Care should always be taken to prevent the 
 bladder from being injured. If it be cut, the wound should 
 be closed with a continuous catgut suture. 
 
 The treatment of the various conditions for which the 
 abdomen is opened will be considered in succeeding 
 chapters. 
 
 During all manipulations it is of great importance that 
 the peritoneal cavity should be kept dry, that all fluids, 
 clots, etc., should be prevented, as much as possible, from 
 entering it, by means of swabs, and that the bowels should 
 not be exposed to the air without being covered in a 
 sterilised towel wrung out of warm sterilised salt solution. 
 
 If the case is one in which the diseased part has beert 
 satisfactorily removed without the necessity of drainage, any 
 small amount of blood or other fluid which has escaped 
 among the intestines should be wiped out with sterilised 
 swabs held in long forceps. These should be passed 
 especially into the pouch of Douglas, care being taken 
 not to disturb the ligatured pedicle. The bowels must 
 not be roughly rubbed during this procedure. 
 
 In the great majority of cases irrigation is not necessary. 
 When pus or the contents of a ruptured cyst, or of ruptured 
 bowel, are widely spread in the abdominal cavity, it is well to 
 
 
 
276 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 J 
 
 wash out the cavity with a sterilised salt solution (o'6 per cent.) 
 at blood heat. The stream should flow gently through a 
 rubber tube from half an inch to three-quarters of an inch in 
 diameter. When the cavity is full the hand of the operator 
 should be cautiously moved among the intestines. The 
 stream should not be directed against the diaphragm, nor 
 should the cavity be too much distended. Dyspnoea, 
 asphyxia, or cessation of breathing may take place if caution 
 be not observed. After irrigation careful sponging must be 
 carried out to remove all the fluid. Some experimenters 
 state that it is impossible to clean the cavity thoroughly 
 by means of irrigation, because of the distribution of the 
 foreign material among the coils of intestines ; others, 
 that thorough sponging alone is not sufficient. Probably 
 a combination of both methods in bad cases is best. 
 
 Clark emphasises the importance of thorough irrigation, 
 on the ground that, even if the foreign matter be not ent'rely 
 removed, it is more broken up and therefore more easily 
 disintegrated by the leucocytes. Muscatello's experiments 
 have clearly demonstrated that the leucocytes act more 
 rapidly in removing foreign particles when they are small. 
 Moreover, the irrigation distributes the noxious matter and 
 prevents it from remaining in a localised area. 
 
 Sometimes a cyst cannot be removed, but must be 
 stitched to the abdominal wound. I will describe the 
 technique in such cases, when they are specially referred 
 to. The method of carrying out drainage is referred to on 
 p. 407. 
 
 Closure of the abdominal wound. — Several methods are 
 adopted. A common one is that in which several sutures 
 are passed through the whole thickness of the walls. 
 Before the sutures are passed, a sterilised gauze pad is 
 placed on the intestines under the wound, in order to keep 
 them out of the way of the needles, and to catch any blood 
 from the stitch-holes. At this stage the assistant in charge 
 of the instruments should see that all are in his possession 
 
 .y. 
 
ABDOMINAL SECTION. 
 
 277 
 
 and that nothing has been left in the abdomen. The nurse 
 in charge of the swabs or sponges should likewise be able 
 to account for all that have been used. None of these 
 should be divided in an operation. 
 
 A number of large full-curved needles are threaded with 
 pieces of thoroughly sterilised silk sutures or of silkworm 
 gut, and are passed by means of Martin's needle-holder 
 through the abdominal wall on each side of the wound, the 
 needle passing through the skin about three-eighths of an 
 inch from the edge. Care must be taken that none of the 
 layers shall retract so far as not to be pierced by the needles. 
 They may be pulled towards the middle line by the assistant, 
 if necessary. 
 
 The sutures are placed about half an inch from one 
 another. When all are passed, the pad is withdrawn from 
 the abdomen, the edges of the wound brought together, and 
 the sutures tightened. Care must be taken to keep intestine 
 and omentum out of the wound. The assistant then keeps 
 the wound closed while the operator ties the sutures ; each 
 knot should have a double turn on the first part. 
 
 jrA\ blood should be swabbed out of the wound while it 
 is being tied. The skin edges are next carefully approxi- 
 mated. If there is gaping at any point, catgut may be 
 used to make closure. 
 
 The suture ends are cut short, the skin surface is dried 
 and made ready for the dressings. 
 
 Another method preferred by many is the following : — The 
 peritoneal edges are brought together by means of a con- 
 tinuous catgut suture. The rest of the wound is closed by 
 a series of sutures passed as already described, including 
 everything but peritoneum. This method is a good one. 
 If suppuration starts in connection with one of the sutures 
 it will not tend to spread to the peritoneum, which has been 
 separately closed. 
 
 Another met.iod is recommended by some, namely to close 
 the wound layer by layer by means ol atgut. It is said 
 
 
^ 
 
 178 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 to lead to a stronger cicatrix. There is no proof of this, how- 
 ever. It takes more time than either of the other methods. 
 
 The dressing. — The wound and navel are thickly covered 
 with an antiseptic powder, e.g. iodoform, napthalene, or 
 a mixture of both. A thin pad of sterilised gauze, or a 
 prepared pad of wool enclosed in gauze, is placed on the 
 wound. This is covered with a single piece of gauze, 
 larger than the pad. The edges of the gauze are fastened 
 to the wall with antiseptic collodion. In this way the 
 dressing is closely fixed to the wound. 
 
 Antiseptic collodion is made as follows : — 
 
 Mix, 
 
 Absolute alcohol . 
 Iodoform . 
 
 Add, 
 
 Ether . 
 
 .-^iii. 
 3vi. 
 
 ,^iii. 
 
 Add, 
 
 Pyroxylin until the fluid is syrupy. 
 
 Williamson recommends highly, for wounds and dressings, 
 a celloidin mixture, e.g. — 
 
 Celloidin 
 
 2 parts 
 
 Absolute alcohol . 
 
 • 15 » 
 
 Pure ether (sp. gr. 720) 
 
 • 15 » 
 
 Over the gauze, pads of dry antiseptic wool are placed. 
 The dressings are held in position by means of a wide 
 abdominal bandage, made of domette or of fine flannel, 
 which has been sterilised ; or strips of adhesive plaster 
 may be employed. The patient is then placed in bed, 
 which has been warmed with hot-water bottles. 
 
 Drainage of the peritoneum. — It is generally considered 
 advisable to drain, when foreign matters have been present 
 in the peritoneal cavity, e.g. pus, blood, contents of the 
 intestinal canal or bladder, cyst contents, when at the 
 closure of the wound there is unchecked capillary oozing 
 
 c I 
 
ABDOMINAL SECTION, 
 
 279 
 
 W 
 
 from the same surface, or where the case is one in which 
 after haemorrhage is to be feared. 
 
 In the great majority of cases a glass tube suffices for 
 drainage. I have already described it and the other 
 methods of drainage, vide p. 268. The tube is usually 
 placed in the pouch of Douglas, passing between a couple 
 of sutures, close to the lower end of the wound. The outer 
 end of the tube should possess a circular flange, which 
 should not project much beyond the skin. 
 
 If the tube be too short, or have no circular flange, it 
 may slip into the abdomen ; if too long, it is apt to be forced 
 inwards upon the viscera. Damage, e.g. perforation of the 
 bowel wall, may be caused in this way. 
 
 The sutures are all tied, except one next the tube, which is 
 left to be tied when the tube is withdrawn. The skin edges 
 around the tube may be kept from gaping by catgut sutures. 
 
 The dressings in such a case are best applied as follows : — 
 A square piece of thin indiarubber sheeting is perforated 
 and fastened to the tube just below the flange. Under it 
 the antiseptic powder and pads ai- placed. In this way 
 any fluid escaping from the tubes does not soak the dress- 
 ings next the wound. Over the tube-mouth a pad may be 
 placed, and the whole covered with absorbent wool, and 
 kept in position by means of an abdominal binder. This 
 must not be fastened tightly. 
 
 The tube may be continuously drained by sterilised 
 gauze or lamp-wick passed into the tube. Generally it is 
 best to withdraw the fluid by means of a syringe with a 
 rubber tube attached, as often as is necessary. 
 
 Sometimes immediately after an operation it may require 
 to be drawn off every ten or fifteen minutes. The intervals 
 should be made as long as possible. When capillary 
 drainage is established, it is apt to be stopped by clots if 
 the discharge is bloody. 
 
 If the syringe will not remove them, a sound with cotton- 
 wool on the end may be used. 
 
 ■ ! 
 
 'If 
 
 I III 
 
y^ 
 
 280 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 If the tube be left in position for twenty or thirty hours 
 or more, it tends to become enclosed in peritonitic ad- 
 hesions. This is sometimes valuable where there has been 
 a tear in the rectum in the removal of a mass from the 
 pouch of Douglas, which has not been well closed during 
 the operation. The faecal matter and gas escape through 
 the tube-tract without infecting the general peritoneal 
 cavity. This faecal fistula may last a long time. 
 
 When intestine has been wounded, gas or faecal matter 
 may pass from the tube, and this may be the first intimation 
 that the accident has taken place. 
 
 Sometimes air only may escape. This has entered during 
 the operation or has been sucked in during attacks of 
 vomiting. 
 
 If the holes in the side of the tube are larger than i mm., 
 the omentum or even the bowel may tend to work its 
 way into the lumen. A series of little herniae may thus 
 form, which, becoming strangulated, may give rise to pain, 
 vomiting, local haemorrhage, and gangrene. This may 
 occur within the first twenty hours of the operation. To 
 prevent it, the tube should be turned around and moved 
 slightly upwards and downwards each time the fluid is 
 removed. 
 
 If the tube should become fixed by the formation of the 
 herniae, rotation may cause the withdrawal of them. But 
 it may be necessary to pull up the tube, ligature the 
 omentum just outside the tube, and cut off the hernial 
 portion. 
 
 The drainage-tube may only be required for a few hours, 
 but it may be needed for several days. It should be removed 
 when the discharge is becoming scanty. 
 
 The longer the tube remains in position the greater the 
 risk of an abdominal hernia. The edges of the tube-tract 
 are slow in healing. 
 
 The tube should be of strong glass. Otherwise it might 
 be broken during an attack of vomiting. 
 
 K 
 
 \\ 
 
ABDOMINAL SECTION. 
 
 281 
 
 When it is withdrawn, the suture that was left untied is 
 securely fastened, and the whole wound is freshly dressed. 
 
 I have already described the plan of draining the peri- 
 toneum by means of a large gauze pack. 
 
 Martin and others often drain the peritoneum by means 
 of a X-shaped tube passed through an opening from the 
 pouch of Douglas into the vagina, which is made at the 
 abdominal section. The tube is carried up the vagina and 
 into the peritoneum by means of forceps, the cervix being 
 steadied at the time by an assistant. The vagina and 
 uterine cavity should be made aseptic before this is carried 
 out. The lower end should be surrounded with iodoform 
 gauze, which must be changed from day to day. 
 
 Within very recent times the question of drainage in 
 abdominal cases has attracted considerable attention. The 
 views expressed by T. J. Clark of Johns Hopkins Hospital, 
 based upon the study of a large number of cases, are 
 worthy of careful study. 
 
 In regard to operative cases, in which there is no primary 
 infection, he emphasises facts which many recognise, namely, 
 that blood within the peritoneal cavity may be absorbed 
 before it coagulates ; that after coagulation it may be 
 removed gradually by the action of leucocytes, or may 
 become encapsulated and organised ; that the absorptive 
 power of the peritoneum is best marked when the tissues 
 are uninjured, but that, even when considerably injured, free 
 blood may be taken up ; that where the peritoneum has 
 been injured, especially if already diseased, there is a special 
 tendency to the pouring out of blood and serum ; that 
 freshly effused blood or serum is actively germicidal for 
 some time, and may be able to destroy many organisms. 
 
 He shows that in a hundred undrained cases, where there 
 were extensive adhesions, only one was complicated by the 
 formation of suppuration after operation, whereas in a 
 hundred similar cases which were drained it occurred in 
 eight. 
 
 iff 
 
 
 ■ i; 
 
 (\m 
 
 \\\ 
 
283 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 Thu introduction of a gauze drain into a raw oozing 
 cavity may check the bleeding but leads to free serous 
 secretion, which is liable to infection from the skin of the 
 abdominal wall. The danger of infection through a 
 drainage- tract is greater after the drain is removed than 
 immediately after the operation. 
 
 When a drain is introduced plastic fibrin forms round 
 about it, causing adhesions to neighbouring peritoneum. 
 If the gauze be removed in this period, great pain is 
 caused, and complications may result, e.g. dragging out 
 through the wound of omentum or intestines, haemorrhage 
 from rupture of a vessel, or separation of a ligature. As the 
 fibrinous covering organises, it becomes less attached to the 
 drain, ovvmg to degeneration of the layer next the drain. 
 From the fifth day this takes place, so that removal A the 
 gauze is more easily carried out after that day. 
 
 In removing the drain the organisms which may have 
 entered the outer part of the gauze may be squeezed into 
 the peritoneum, and thus set up infection. 
 
 In cases where infectious matter is supposed to exist at 
 the time of operation, e.g. pyosalpinx, ovarian abscess, etc., 
 the researches of Miller and others have proved that the 
 great majority of fluid collections are sterile, and Clark 
 shows that the results of treatment in such conditions are 
 very much more satisfactory where no drainage is employed. 
 Drainage is often associated with obstinate constipation, 
 tympanites, nausea and vomiting, owing to the constrained 
 position of the intestines around the drains. Fiecal fistula 
 may also be produced. Sometimes the inflammatory 
 reaction around the drain may cause vesical irritation, 
 cystitis, and dysuria ; the bladder may be interfered with 
 in its movements, or a suppurating tract may open into it. 
 Cases in which drainage is employed are more apt to be 
 followed by hernia than those in which no drainage is used. 
 In order to avoid the necessity for drainage, Clark insists 
 upon careful attention being paid to the following points : — 
 
 ' I 
 
 '\ 
 
ABDOMINAL SECTION. 
 
 283 
 
 w 
 
 1. Thorough disinfection of the hands of the operator 
 and his assistants. 
 
 2. The careful control of hnemorrhage. 
 
 3. The avoidance of bruising and injuring of the tissues. 
 
 4. The isolation of the general peritoneal cavity during 
 the operation. 
 
 5. The sacrifice of as little as possible of the peritoneum. 
 
 6. The conservation of bodily heat. 
 
 7. The avoidance of rupture of intraperitoneal abscesses. 
 
 8. Irrigation of the peritoneal cavity, with normal salt 
 solution after operations, where debris or normal fluids 
 escape into the peritoneal cavity. 
 
 9. The retention in the peritoneal cavity of 500 to 
 1000 cc. of normal salt soluti^^n, after operations which 
 have been prolonged, or in which the presence of 
 septic matter has been suspected. This should be asso- 
 ciated with the elevation of the foot of the bed for 
 twenty-four hours after the operation, in order that the 
 matter should not collect in one part, namely, in the pelvis, 
 but should be distributed through the peritoneal cavity, so 
 that the forces which are employed in removing the foreign 
 matter may act at the best advantage. For the matter will 
 be broken up in the dissemination, irritating toxins will be 
 diluted, and more leucocytes will be brought into relation- 
 ship with the foreign bodies. 
 
 This postural drainage is only to be regarded as a pro- 
 phylactic against post- operative peritonitis, and is not to 
 be used after the peritonitis is established. In purulent 
 peritonitis it is of no use, for Pawlowsky has demonstrated 
 that in this condition the lymph channels leading from the 
 peritoneum are choked with microbes and inflammatory 
 products ; free drainage through an incision is better in such 
 cases. Where ascites is present it is also best not to 
 employ the postural method, Waterhouse having shown that 
 absorption from the peritoneal cavity is impp-^*ect where 
 that condition exists. 
 
 
284 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 I 
 
 10. The injection of normal salt solution into the cellular 
 tissue beneath the breasts, if symptoms of infection arise 
 after operation. 
 
 After-treabment of abdominal sections. — The patient 
 lies at rest on her back. For the first twenty-four or 
 thirty-six hours nothing should be given by the mouth, 
 except where the patient is very young, old, or ex- 
 hausted. If it be necessary to feed early, it is best to 
 do so by the bowel. With some the rule is to give nothing 
 until flatus is passed by the rectum. If the patient be 
 doing v/ell and be not sick on the evening of the second 
 day, a little milk and hot water, or milk with lime-water, 
 may be given in sips. On the third day, the same may 
 be given in the morning and evening ; on the fourth day, 
 milk and water may be given in the morning, weak tea 
 with milk in the afternoon, chicken or beef-jelly, gruel 
 or arrowroot in the evening. During the night one or 
 other of the same articles may be given. On the fifth 
 day, beef-tea, chicken-tea, or milk-pudding may be added ; 
 on the sixth day, fish ; on the seventh and succeed- 
 ing two or three days, chicken may be added to the 
 dietary. 
 
 There may be nausea after the operation -, it may last 
 for twelve, eighteen, or twenty-four hours, or may be more 
 prolonged. If prolonged, the administration of food by the 
 mouth must be postponed. 
 
 For the nausea and vomiting, nothing should be given 
 for some hours. Then bismuth and hydrocyanic acid 
 mixture may be tried, sips of champagne, or sodium bicar- 
 bonate dissolved in hot water (5 grs. to §i.) given in the 
 dose of a couple of tablespoonfuls. Also a mustard leaf 
 over the epigastrium may give relief. 
 
 In bad cases sometimes a hypodermic of morphine will 
 check the vomiting. The head should not be much higher 
 than the body in such cases. 
 
 In long-continued vomiting, wheie the patient is weak 
 
ABDOMINAL SECTION. 
 
 285 
 
 and requires food and stimulant, nutrient enemata may be 
 given. The following is a good mixture : — 
 
 Peptonised milk . . . 5i.) 
 Brandy .... ^i-) 
 The whites of two eggs ; add a little salt. 
 
 Or a mixture of peptonised beef-tea with brandy may be 
 given. If necessary, strophanthus or digitalis may be added 
 to these. 
 
 Nutrient suppositories are also used. 
 
 Before nutrient enemata are given it is well to wash out 
 the rectum with warm salt solution. No ice should be 
 given. Cold black coffee is often well borne. 
 
 As regards the bowels, nothing passes save flatus for 
 some days. If gas tends to collect and cause the patient 
 any annoyance, a rectal tube should be passed to enable 
 the flatus to escape. 
 
 If all goes well, on the evening of the third day a saline 
 aperient should be given (earlier if there is much distension 
 and trouble). If there is nausea, however, it is best to pro- 
 duce an evacuation on the morning of the third day (or 
 earlier) by an enema of soap and water (i pint), to which 
 may be added, if desired, an ounce of Epsom salts, or this 
 may be preceded, an hour before, by warmed olive oil or 
 glycerin (6 oz.). 
 
 On succeeding days, cascara by the mouth, or glycerin 
 suppositories by the rectum, may suffice to keep the bowels 
 regular. 
 
 After the first opening of the bowels, the patient some- 
 times feels weak. For this condition a nutrient enema, 
 with brandy, is valuable. 
 
 The patient is generally greatly troubled with thirst. She 
 must be encouraged to restrain the desire to drink, and must 
 not be allowed to take fluid by the mouth. She may rinse 
 out the mouth or suck a rag dipped in water, and get relief. 
 Sometimes an enema of warm water may help the patient. 
 
 '. I il 
 
 %\ 
 
 
 
 e 
 
 
 
r 
 
 386 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 The bladder should not be emptied with a catheter unless 
 absolutely necessary. During the evening after operation, 
 the patient should try to pass water. If she is not able, she 
 should again try during the night. A warm cloth over the 
 vulva may assist her. If she fail, the nurse should draw off 
 the urine under strict antiseptic precautions. This may be 
 done every six hours, if necessary. 
 
 Pain is generally felt in the pelvis after sections. It varies 
 greatly in intensity in different cases, is not dependent upon 
 the seriousness of operation, and has a good deal to do 
 with temperament. It generally begins to improve after 
 twenty hours or thereabouts, and passes off, usually, within 
 the next twenty-four hours. 
 
 The ordinary cause of pain is constriction of the pedicle, 
 and also of the abdominal wall by the wound sutures. It 
 is aggravated by vomiting. Other pains may be due to 
 stitch abscess, to blood extravasation, to neuralgic con- 
 ditions in weakly women, and sometimes to peritonitis. It 
 must be remembered that there may be little or no pain 
 with the septic peritonitis following an abdominal section. 
 
 For pain nothing should be given, if possible. The 
 patient should be encouraged to fight against it. Sometimes 
 morphine may be required. Where the person has been 
 accustomed to this drug it will probably be of little service. 
 
 Restlessness is a common condition. For this the nurse 
 must try to arrange the pillows and bedclothes so as to give 
 the patient more comfort. Sponging of the limbs and chest 
 with warm alcohol, or with warm soap and water, may be 
 tried after the second day, if the patient be not too ill or 
 restless. After each part is sponged it should be dried and 
 covered. There should be no exposure leading to a chill. 
 This may be regularly carried out during convalescence. 
 Excessive restlessness may, however, require a hypodermic 
 injection of morphine or an enema of sodium bromide (3i.) 
 or of paraldehyde (3ii.) in syrup and water. 
 
 The pulse, after operation, if the case proceeds well, 
 
ABDOMINAL SECTION. 
 
 287 
 
 is slow and regular. It may be quickened by internal 
 haemorrhage, peritonitis, and various other conditions, e.g. 
 restlessness, temper, nervous temperament, etc. 
 
 The temperature, in an ordinary case, usually rises in the 
 evening of the day of operation, and afterwards gradually 
 falls to the normal, where it remains. It may be subnormal 
 where there has been much shock or depression, or where 
 marked internal haemorrhage has occurred. It may be 
 elevated by various conditions, e.g. disturbed stomach, 
 tympanites, nervousness, inflammation, formation of a 
 haematoma or haematocele, etc. There may be marked 
 rises of the temperature with peritonitis, though in some 
 cases it may be normal or subnormal. 
 
 The tongue should in good cases be moist, free from 
 coating, and of normal colour. It may be coated from a 
 disordered stomach, or may be stained light brown from 
 bilious vomiting. In peritonitis it has various appearances. 
 It may be covered with a yellowish coating, or may be 
 rough and dry. Where suppuration is going on to any 
 extent, it may be dry, smooth, and of a bright red colour. 
 
 The occurrence of tympanites must be watched for care- 
 fully. It causes colic, pain, and distress, and may quicken 
 pulse and breathing, interfering with the action of heart and 
 lungs. It may be due to intestinal disorders or to peri- 
 tonitis. Distension is very often the earliest indication of 
 peritonitis, and, in such a condition, usually appears on the 
 third day. Tympanites may follow the removal of large 
 tumours, but this form is usually painless. The rectal tube 
 should be used to draw off the flatus, or an enema should 
 be given containing : — 
 
 Warm water 
 Warm olive oil 
 Turpentine 
 
 r pmt. 
 
 2 oz. 
 
 I tablespoonful. 
 
 A turpentine stupe on the abdomen may also be tried. 
 The stitches should not be removed from the abdominal 
 
 'Hi 
 
288 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 wall until the bowels have been moved. A dose of an 
 aperient should be given on the evening previous to the 
 day of their removal, so that there may be a motion in 
 the morning before the stitches are taken away. 
 
 On the morning of this day it is also a convenient time to 
 change the patient's night-dress and the bed-linen, because, 
 after removal of the stitches, it is necessary that she should 
 be kept very quiet. This changing must be carefully carried 
 out. 
 
 Ordinarily the stitches may be removed on the ninth 
 day. If a drainage-tube has been employed, so that one 
 stitch is later than the others, all may be removed save this 
 one, or all may be left until the tenth or eleventh day. 
 
 Before removing the sutures, the line of the wound and 
 the suture ends are carefully washed in antiseptic lotion. 
 Each stitch is removed by means of a pair of forceps and 
 a pair of scissors. The knot is pulled outwards, the skin 
 depressed a little by the scissors, the suture cut below the 
 skin-level and drawn out of the wall by the forceps which 
 are attached to the knot. 
 
 Antiseptic powder is then sprinkled along the line of the 
 incision. This is covered with a narrow piece of wool. 
 Across this are placed strips of perforated adhesive plaster, 
 the abdominal walls being well drawn towards the middle 
 line by an assistant before the plaster is applied. 
 
 If no suppuration occur, this dressing may not require to 
 be changed for some time. 
 
 By the fifteenth or sixteenth day, the patient may be 
 allowed to sit up somewhat in bed, being propped up with 
 pillows. After two or three days, if all goes well, she may 
 be allowed to sit up in a chair for a little, and, on the 
 following days, to walk a little. Before being allowed up, 
 she should be fitted with an abdominal belt, which should 
 be worn constantly, a light one at night, a strong one by day. 
 
 During the fourth week the patient may go home. She 
 must be told to avoid all exertion, to be careful with her 
 
ABDOMINAL SECTION. 
 
 289 
 
 diet, to keep the bowels regular, to avoid coitus for four 
 months, and to wear the belt for a couple of years. After 
 six months she need not wear a night-belt. 
 
 Complications after operation. — Shock. — After most 
 cases of abdominal section there is some depression, the 
 patient being pale, the pulse small, soft, increased in 
 frequency (sometimes slow). Sometimes shock is a very 
 marked feature. It is generally due to lengthened anaes- 
 thesia, haemorrhage, reduction of temperature, especially 
 from the exposed peritoneum, irritation of the peritoneum 
 during the manipulations, or as a result of pouring large 
 quantities of fluid into the abdomen. The dangerous 
 element in shock is the failure of the heart's action. 
 Death may occur during the first, second, or third day. It 
 is most to be expected in old, weak, or anaemic women. 
 
 Hcevwrrhage. — Internal haemorrhage may be due to 
 various causes. The most common causes of severe bleed- 
 ing are slipping of the pedicle ligature, loosening of it, and 
 retraction or shrinkage of some part of the pedicle. In 
 most cases such a calamity occurs on the first or second 
 day, though it may be later. It may be associated with the 
 straining of vomiting or coughing. 
 
 Haemorrhage also may take place from torn adhesions. 
 In all these cases it is intraperitoneal. Sometimes extra- 
 peritoneal bleeding may occur, e.g. in the broad ligament. 
 This may sometimes force the ligature from the pedicle, 
 and may burst into the peritoneal cavity. Haemorrhage 
 may also occur in connection with the abdominal wound 
 when the patient has haemophilia, leucocythaemia, bad 
 jaundice, or purpura. 
 
 If a drainage-tube has been used, the internal 
 haemorrhage may soon be detected. If not, the symp- 
 toms and physical signs indicate the condition. The 
 pulse becomes rapid and thready, the temperature falls, the 
 face gets pale and waxy. Respiration increases. Patient is 
 thirsty, restless, and pants for air. She may faint, may see 
 19 
 
 1 ',: 
 
 N 
 
 
''/;»WWk 
 
 V, 
 
 290 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 everything darkly, or may see dark spots before her eyes. 
 She feels giddy. If the case has a fatal issue she gets 
 collapsed, pupils dilate, pulse gets unrecognisable, temper- 
 ature falls, and limbs become cold. On bimanual or 
 abdominal examination a boggy, indefinite fulness may be 
 made out — dull on percussion in the flanks. If the blood 
 is extraperitoneal, its circumscribed and unilateral position 
 may be determined. 
 
 In all cases, as soon as haemorrhage is suspected, if no 
 drainage-tube has been used, remove a stitch or two near 
 the lower end of the wound, and pass a tube deeply into the 
 pelvis in order to determine the presence of blood. When 
 haemorrhage is detected, the abdominal wound should be 
 reopened, and the source of haemorrhage found. 
 
 If the pedicle has slipped, it should be caught up and 
 religatured. If this be impossible, hold the raw edges 
 by forceps, ligature the ovarian, and, if possible, the 
 uterine artery of the bleeding side. The raw edges should 
 then be closed with continuous catgut suture. The blood 
 is then washed out of the peritoneal cavity. Sterilised salt 
 solution should be used, some of it being left in the cavity 
 to be absorbed into the system, thus serving instead of 
 transfusion. 
 
 When oozing goes on from adhesions, the drainage-tube 
 being left in the wound, it is well to apply a compress to 
 the abdomen, taking care not to put pressure on the tube. 
 Wool is placed on the abdomen, thick cloths on each 
 side, and an elastic binder over all. A firm vaginal plug 
 may be introduced. In bad cases the abdominal wound 
 must be reopened, and the operator must endeavour to 
 check the bleeding by cautery, ligatures, or pressure. In 
 cases of bleeding from a large raw surface, packing of the 
 cavity with iodoform gauze may be tried. 
 
 When the haemorrhage is extraperitoneal, ice-bags may 
 be applied to the abdomen, and ergot given internally. 
 
 In all of these conditions, the general treatment of 
 
ABDOMINAL SECTION. 
 
 291 
 
 haemorrhage may require to be carried out, e.g. stimu- 
 lants internally or hypodermically, warmth, bandaging 
 of limbs, rectal injection of warm solution of salt (3i. 
 to Oi.). 
 
 Sepsis. — Most of the deaths in the first week are due to 
 sepsis. Some cases, in which the cause is put down 
 as heart - failure, are undoubtedly due to septicaemia. 
 Examination of the blood or of the peritoneum, though 
 there may be no peritonitis, may reveal germs. The septic 
 attack may be acute, and death may be sudden, or a more 
 chronic process may be set up. Peritonitis may or may 
 not be present. It is often widespread. 
 
 The septic process often begins on the first day. The 
 temperature rises, but this varies considerably in different 
 cases. There may be rigors. The pulse increases markedly. 
 The worse the case, the more marked the difference between 
 pulse and temperature. Vomiting is often bad. The patient 
 becomes exhausted. The face is peaked and anxious. 
 
 When septic peritonitis is present, the symptoms usually 
 develop first on the third day. Tympanites develops, and 
 tenderness on pressure. If the patient feels pains, they 
 are not often severe, and may disappear after a few days. 
 The vomiting may be bad, but may vanish. Pulse gets 
 soft and quick. The temperature varies greatly. Patient 
 is weak. The face is anxious, and the eyes appear sunken 
 with dark rings around them. The intellect is generally 
 quite clear. The tongue gets dry and brownish. 
 
 Treatment. — An enema of warm soap-suds (Oss.), turpen- 
 tine (5SS.) and castor-oil (31.), or sulphate of magnesia (si.) 
 should be given, and at intervals of four or five hours a 
 simple turpentine enema should be administered. The 
 rectal tube may be passed at intervals. It is a good sign 
 when flatus passes. 
 
 By the mouth, calomel and salines should be given 
 alternately, in order that purging may be produced. 
 
 No morphia is to be given, unless the patient be beyond 
 
 
V 
 
 393 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 recovery. Brandy and champagne are to be given by the 
 mouth or in nutrient enemata. 
 
 The abdomen is not to be opened, save where there is 
 evidently a collection of pus in it. If there be extra- 
 peritoneal pus, it may be opened through the vagina or 
 elsewhere. , , * 
 
 Local inflammation. — A localised peritonitis in the pelvis 
 may take place, probably due to germ infection, often with 
 the irritation of some foreign body, solid or fluid. Adhesions 
 form, and the inflammation does not become general. Also, 
 localised cellulitic inflammations may occur. It must also 
 be remembered that blood collections may break down and 
 suppurate. 
 
 When these cases go on to pus formation, the pus tends 
 to burrow, and to escape either into the peritoneal cavity, 
 bowel, bladder, vagina, or through the abdominal wall. 
 
 Thrombosis may occur in neighbouring vessels, and 
 pyaemia or embolism may result. 
 
 The clinical symptoms are pain, sweating, rigors, rises of 
 temperature, headache, nausea, or vomiting. After a time 
 hectic develops. v '• 
 
 These inflammations in their early stages may be treated 
 by purging, blistering, and the hot douche. When pus forms, 
 it may be removed, and the cavity drained, if possible, 
 per vaginam. Inflammation may also occur around the 
 stitches in the abdominal wall. The great cause is imper- 
 fect asepsis. The inflammation ends in pus formation — 
 stitch abscess. In such cases the suture affected must 
 be removed, and, if necessary, the openings enlarged so 
 as to allow of free outward drainage and washing-out with 
 antiseptics. 
 
 Opening of the abdominal wound. — This may occur before 
 the stitches are removed, if they be not of good material, 
 and if there be any great strain on them, e.g. coughing. 
 Generally it occurs after they are removed too early, because 
 of imperfect strapping or because of increased intra- 
 
 •f\ 
 
ABDOMINAL SECTION. 
 
 293 
 
 abdominal pressure. Sepsis in the wound is also a cause 
 of weakening of the wall. The wound must in such cases 
 be closed, the wound and bowels being carefully washed if 
 suppuration be present, and a drainage-tube inserted into 
 the peritoneal cavity. 
 
 Intestinal obstruction. — This accident may occur after 
 abdominal section. It may be due to an adhesion of the 
 bowel and pedicle ; to the incarceration of a loop of gut 
 between the pedicle and some other part, when the former 
 has been fastened to the abdominal wound ; to twisting of 
 the gut during the operation ; to the inclusion of gut in the 
 abdominal wound ; to the passage of a suture through 
 bowel; to adhesion of bowel and abdominal cicatrix; 
 to constriction by haematoma of the broad ligament ; to 
 atony of the bowel wall and tympanites ; to the same con- 
 dition in peritonitis ; to matting together of the bowels in 
 chronic peritonitis. The obstruction may occur soon after 
 the operation or not for months. The treatment is to do 
 abdominal section and relieve the obstruction. 
 
 Tetanus. — This occurs in a certain percentage of cases. 
 According to Olshausen, it takes place in cases in which 
 the clamp has been used, in those in which the pedicle is 
 treated extraperitoneally by means of perforating needles or 
 the wire serre nceud, and also in cases where the pedicle is 
 ligatured and treated by the intraperitoneal method. The 
 tetanus is probably related to imperfect ligature of the 
 pedicle, whereby the nerves were not thoroughly compressed, 
 but left in an irritable state. 
 
 The treatment is that of tetanus in general. Locally it 
 may be necessary to tighten the constricting clamp, or to 
 remove it, along with the perforating needles. Sometimes 
 excision of part of the end of the stump may be required. 
 
 Perforation of bowel. — This may be due to a cut at the 
 time of operation, to a tear made in separating adhec'ons, 
 to the giving way of a stitch after an operation on the bowel 
 wall. It may follow intestinal obstruction, or may result 
 
294 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 from the bursting of pus into the bowel ; from the pressure 
 of a drainage-tube, or the irritation of a ligature. It may 
 be due to malignant disease, or may follow opening of the 
 abdomen for tuberculosis, due to the giving way of a tuber- 
 cular ulcer. 
 
 Treatment. — When the gut is wounded in operations, it 
 should be closed with Lembert sutures. In the case of a 
 diseased wall or a large tear, it is best to sew the opening to 
 the edges of the abdominal incision. When the opening 
 occurs in the rectum in the pouch of Douglas, if possible it 
 should be closed with sutures on the peritoneal side. If 
 this cannot be done, a large drainage-tube, passed out of 
 the abdominal wound, may be employed. Little food, no 
 purgatives, and no enemata should be given. 
 
 Some use a plug of iodoform gauze for a few days. In 
 addition, a colotomy may be performed, in order to prevent 
 faeces passing down the rectum. When a faecal fistula forms, 
 it should be dressed carefully. After it has existed for a 
 time its closure should be attempted. 
 
 Ventral hernia. — This may result from careless closure of 
 the wound, i.e. from not bringing towards the middle line 
 all the elements in the edges of the wound ; carelessness on 
 the part of the patient in regard to the wearing of her belt ; 
 over-exertion, e.g. straining at stool, lifting, coughing, or 
 vomiting. It is more common after hysterectomy than 
 after other forms of abdominal section. The use of the 
 drainage-tube, or suppuration in the wall, tends to lead 
 to a weakening in the wound, which may be followed by 
 hernia. 
 
 The treatment is to open the abdomen, excise the old 
 cicatrix, and to close the wound layer by layer. 
 
 Parotitis. — This may occur on one or both sides. As 
 a rule it develops from five to seven days after operation. 
 It may be associated with sepsis. There is pain locally 
 and elevation of temperature. The swelling may subside 
 or suppurate. 
 
 W 
 
VAGINAL SECTION. 
 
 395 
 
 , , , Vaginal Section or Colpotomy. 
 
 Recently several gynecologists, notably Martin of Berlin, 
 have recommended the treatment of various diseased pelvic 
 conditions by means of an opening into the peritoneal cavity 
 made through the anterior fornix of the vagina, instead of 
 one made through the abdominal wall. It is claimed that 
 the operation is a safer one for the woman, and not attended 
 with the after-troubles or dangers associated with abdominal 
 section. 
 
 The operations which may be carried out by this method 
 are:— 
 
 1. Removal of myomata not larger than a foetal head. 
 
 2. Removal of small ovarian tumours. 
 
 3. Ovarian resection and destruction of small cysts. '• 
 
 • 4. Removal of inflamed tubes and ovaries, pyosalpinx, 
 hydrosalpinx, haematosalpinx. 
 
 5. Removal of early tubal pregnancy. 
 
 6. Vaginal fixation of a retroverted uterus. 
 
 7. Breaking of peritonitic adhesions to uterus, except 
 those deep in the pouch of Douglas. 
 
 Preparation for the operation. — The patient is prepared 
 in the careful manner already detailed on p. 249. Strict 
 asepsis is aimed at throughout the operation. 
 
 The operation. — The patient is placed in the lithotomy 
 position and anaesthetised. The hair of the vulvar region 
 is shaved, and the genital tract, the vulva, and the buttocks 
 are made aseptic. The patient's legs should be covered 
 with long sterilised linen stockings. During the operation 
 irrigation of the wound should be carried out with hot steril- 
 ised salt solution. 
 
 First, a short broad-bladed spatular speculum is intro- 
 duced into the vagina to pull back the posterior wall. 
 Orthmann's combined sound and volsella is then used to 
 steady the uterus; the sound enters the uterus, and the 
 volsella grasps the anterior lip of the cervix. If the sound 
 
 ''II 
 
296 
 
 OPERATIVE MEASURES IN GENERAL. 
 
 cannot be passed, an ordinary volsella must be used. The 
 uterus is then pulled downwards and backwards. With 
 another volsella the anterior vaginal wall is held near the 
 urethral orifice. A vertical mesial incision is then made 
 through the anterior vaginal wall, and is carried on to the 
 cervix. On each side of this line the wall is separated from 
 the bladder and cervical musculature. The bladder is then 
 separated from the cervix as far up as the peritoneal 
 reflection. 
 
 This layer is caught with forceps and carefully opened. 
 There is usually little haemorrhage. Bleeding points may 
 be twisted or tied with catgut. When the peritoneal opening 
 is fully made, the pelvis is explored with the fingers. Small 
 adhesions may be broken down with the fingers. Large ones 
 may be ligatured and divided if they are within access. The 
 diseased condition is then attended to. If parts are to 
 be removed — e.g. inflamed ovaries — the pedicle is treated 
 exactly as in cases of abdominal section. 
 
 Method of closure of the incision. — With Martin's full- 
 curved needle, catgut sutures (No. 3) are passed through the 
 upper part of the vaginal wound, cellular tissue at base of 
 bladder, peritoneum, and anterior wall of the cervix. These 
 are then tied in the vagina. With continuous catgut the 
 rest of the vaginal wound is completely closed. Care must 
 be taken not to injure the ureters. Martin passes the 
 sutures through the anterior wall of the body of the uterus, 
 in order to bring about a vaginal fixation of the uterus. 
 This plan must not be carried out if there is a chance 
 of pregnancy succeeding. There is risk of danger in the 
 labour. 
 
 After-treatment. — The patient is kept at rest in bed, the 
 same rules to be observed that are followed in abdominal 
 section. The urine is not to be drawn off unless necessary. 
 Iodoform pessaries may be introduced into the vagina from 
 time to time. 
 
 Qn the fifteenth or sixteenth day usually the patient may 
 
VAGINAL SECTION. 
 
 «97 
 
 be allowed to sit up. From this time onwards the vagina 
 should be carefully douched daily for two or three weeks 
 with a formalin or sublimate solution (i in 3000). 
 
 In women who do not possess a roomy vagina this opera- 
 tion should not be attempted, e.g. in virgins. Some 
 operators prefer to open the peritoneum through the 
 posterior fornix. 
 
 % ■ 
 
 -V"' ' 
 
 1 '■:- 
 
 '' \ 
 
V. 
 
 CHAPTER X. 
 
 AFFECTIONS OF PERITONEUM AND CELLULAR 
 TISSUE— PERITONITIS. 
 
 
 Inflammation of the peritoneum, like inflammation of 
 every other part of the body, is not to be regarded as 
 a specific process working per se towards a calamitous 
 end. 
 
 It has a beneficent purpose, being nature's method of 
 defending her tissues when injured, of repairing inroads 
 made by the enemy, and of destroying and removing the 
 latter. In the great majority of instances, the inflammatory 
 process is directed against the action of micro-organisms 
 or their deleterious products. Recognising these facts, the 
 aim of the student should be — first, to look carefully into 
 the causation of inflammatory attacks, seeking especially to 
 relate them to the exact mode and origin of the infective 
 processes which have led to them ; secondly, in carrying 
 out treatment, to work in the direction of removing from 
 the tissues the irritants already there, and to prevent the 
 entrance of fresh ones from the outside. 
 
 In most fatal cases of peritonitis, the chief symptoms 
 are those due to systemic poisoning, death being due to 
 toxic infection rather than to the changes in the peritoneum. 
 It is noteworthy that in these cases there is no constant 
 relationship between the severity of an attack and the. 
 local changes in the peritoneum. In some of the worst 
 cases very slight peritoneal changes may occur before death 
 supervenes. This is due to the fact that the virulence of 
 
 I 
 
INFLAMMA TION. 
 
 299 
 
 the poison has affected the whole system before the de- 
 fensive peritoneal reaction has had time to manifest itself 
 to any extent. Then, again, some of the most favourable 
 cases are those in which extensive alterations have occurred 
 in the peritoneum in its widespread efforts to destroy and 
 eliminate the toxic material. No doubt, in many cases, 
 there are also distinct effects produced, due directly to the 
 inflammatory process itself. 
 
 In the pelvis, the sources of infection are many. The 
 most important is the genital tract — but the bladder and 
 bowel may also afford entrance to toxic matter. As re- 
 gards the influence of traumatism, apart from infective 
 processes, we know very little. In the pelvis, it plays a 
 very small part, /^/* se^ in the production of pelvic inflam- 
 mation. Its importance consists in the opportunity given 
 for the entrance of germs through the raw or injured 
 surfaces produced by it. 
 
 The following points in regard to the peritoneum in 
 general have been pointed out by Treves, and are worthy 
 of notice : — 
 
 Its whole surface is probably as great as the skin-area of 
 the body. It has marked powers of absorption, taking up 
 milk, blood, peptones, etc., rapidly. It is said to be able to 
 absorb an amount equal to 3-8 per cent, of the body weight. 
 Septic intoxication occurs more quickly in peritoneal infec- 
 tion than in any other. The peritoneum offers a limited 
 resistance to microbes and their products. It can, however, 
 destroy a certain quantity of these. Its power in this 
 respect varies greatly, being affected by the state of health, 
 age, etc. Then, no doubt, there are individual differences, 
 and also variations according to the part of the peritoneum 
 affected. 
 
 That which covers the small intestine is most sensitive 
 to infection and to a rapid spread of inflammation. The 
 parietal peritoneum is less susceptible. The most marked 
 changes are usually found on the visceral and omental 
 
300 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 layers. Localised or encysted peritonitis is rare in the area 
 of the small intestine. 
 
 The peritoneum is very sensitive, though it does not feel 
 pain as does the skin. There is more or less distress to 
 the unanaesthetised patient on handling it. When the 
 peritoneum is bathed in lymph or pus, the ordinary sensi- 
 bility is diminished or absent. 
 
 Bacteria and their products are the irritants which most 
 acutely affect the peritoneum. Fluids do not gravitate to 
 the pelvis from different parts of the peritoneal cavity with 
 the readiness which might be expected. This is in some 
 way related to the influence of intra-abdominal pressure ; 
 though, of course, in some instances adhesions cause the 
 retardation. The frequency with which intestinal contents 
 fail to escape after rupture or perforation of the gut has 
 been noted, and is believed to be due to the effect of intra- 
 abdominal pressure. 
 
 It is possible that the peritoneum may acquire some 
 degree of immunity from septic infection. Ceteris paribus^ 
 abdominal operations in those who have had chronic 
 peritonitis or frequent attacks of a subacute nature are 
 less likely to be followed with bad results than those in 
 whom the peritoneum is normal. 
 
 Etiology of peritonitis in general. — i. Infection may 
 spread from the interior of the alimentary tract, in connec- 
 tion with hernia, intestinal obstruction, rupture, perforation, 
 etc. Generally, it is the Bacterium coli cofntnune or its 
 products which is associated with this variety. 
 
 This organism exists throughout the whole length of the 
 alimentary tract, and is the most numerous of all the 
 microbes there found. If it be taken from the intestine 
 and grown, a culture has no bad effect on the peritoneum 
 of animals. 
 
 It seems to get virulent when the bowel wall is injured 
 or diseased or impaired in vitality to any degree, e.g. in 
 obstruction of the gut, in diarrhoea, cholera, marked con- 
 
 I \ 
 
ETIOLOGY OF PERITONITIS. 
 
 301 
 
 stipation. In such conditions it tends to invade the wall, 
 and to spread into neighbouring tissues. 
 
 When a virulent culture is injected into the peritoneum 
 of animals, the effect varies according to the dosage. The 
 peritonitis usually becomes purulent. 
 
 2. Infection may enter the peritoneum from sources other 
 than the alimentary tract, e.g. from operati\e procedures, 
 from septic processes in the neighbourhood of the peri- 
 toneum, from general septic conditions, etc. The most 
 common germ associated with these forms is the Strepto- 
 coccus pyogenes. Staphylococcus is seldom found alone 
 in peritonitis, but usually with more active cocci. Experi- 
 ments show that pyogenic cocci are more active if intro- 
 duced into the peritoneum with a fluid difficult of absorption, 
 01 with one which damages the endothelium. The germs 
 may be implanted directly on the peritoneum, or may reach 
 it through lymphatics and blood vessels. 
 
 3. Infection may be due to the entrance of certain 
 specific organisms, e.g. pneumococcus, tubercle bacillus. 
 It is also associated with gonorrhoea. 
 
 The pneumococcus may sometimes set up peritonitis in 
 cases of pneumonia by passing down through the diaphragm, 
 but, in many cases, it may not cause any harm in the 
 peritoneum. As regards the gonococcus, many believe that 
 it does not, per se, cause general peritonitis, for experiments 
 seem to show that it does not survive in the peritoneal cavity. 
 It is thought that the inflammation is set up by pyogenic 
 cocci, which have developed in the discharges due to the 
 action of the gonococcus in the lower genital tract {vide 
 
 P- 155)- 
 
 4. Peritonitis may occur in connection with nephritis, 
 
 rheumatism, gout, alcohoHsm, syphilis, etc., in a manner 
 not well understood. 
 
 5. It is generally believed that it may result from local 
 irritation apart from specific infection. This is, however, a 
 difficult matter to establish. Certain it is, of course, that 
 
 MM, 
 
V 
 
 r« 
 
 302 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 Sterilised croton oil and other irritants, if introduced into 
 the peritoneal cavity, will cause peritonitis. But it is not 
 easy in these experiments to eliminate the influence of the 
 microbes in the alimentary canal, or their chemical pro- 
 ducts, passing through the injured coat of the gut. 
 Jalaguier has shown that sterilised gauze placed in the 
 abdomen may cause no reaction unless it be of a certain 
 size, and that, if large, no sympton^ may follow, though in 
 course of time it gets covered with adhesions. Sterilised 
 faeces causes no ill effect in the peritoneum. Freshly 
 filtered fluid from the gut, however, causes peritonitis when 
 placed in the peritoneal cavity. 
 
 Bile introduced sometimes causes it, and sometimes does 
 not, varying according to whether it contains germs or 
 not. The Bacterium coli commune has been found in bile 
 in inflamed conditions of the duct. Blood alone will not 
 cause peritonitis, but it is a splendid nidus for germs. 
 
 I. Acute Peritonitis. 
 
 Pathology. — The changes produced vary greatly as 
 regards their nature and quantity. 
 
 There is at first increased congestion and redness. This 
 may be uniformly or irregularly distributed, being often 
 most marked where the coils of bowel touch. The surface 
 of the peritoneum usually gets dull, swollen, and softened. 
 The minute changes are subserous oedema \ transudation 
 of serum and leucocytes from vessels ; proliferation of con- 
 nective tissue corpuscles ; changes in the endothelial cells, 
 and proliferation of some of them ; formation of vascular 
 granulations. 
 
 Small petechiae may be present. Fibrinous exudation 
 takes place, with very little serum, in many cases; organisa- 
 tion takes place, and lymph is deposited on the peritoneum, 
 at first soft, afterwards firm. This thickens in regular or 
 irregular masses, and tends to mat together adjacent struc- 
 
 \ \ 
 
f 
 
 ACUTE PERITONITIS. 
 
 303 
 
 tures. As the inflammation advances, it tends to form 
 thickenings and adhesions. This variety is known as 
 adhesive peritonitis. 
 
 In other cases, there is only a slight degree of fibrinous 
 exudation, the marked feature being pouring out of serum. 
 This may be almost pure like ascitic fluid, or may be mixed 
 with some fibrinous exudation, forming a serofibrinous 
 mass. The more abundant the latter constituent, the more 
 tendency to coagulation does it show. Lymph flakes may 
 be seen floating about, and they may get deposited on the 
 peritoneum. The fluid may remain free or may become 
 encysted. As it gets absorbed, adhesions and thickenings 
 tend to remain. This variety is known as serous peri- 
 tonitis. 
 
 In the most extreme cases of acute peritonitis, there is 
 pus formation. The pus may be mixed with serum, or may 
 be thick and white. It may be discoloured, foul-smelling, 
 or mixed with blood in various proportions. The pus 
 generally works its way to the pelvis, but often it remains 
 in other parts where adhesions may help to determine its 
 position. This form is known as purulent peritonitis. 
 Sometimes the peritoneal fluid is of a colloid or gelatinous 
 consistence. 
 
 Sometimes foul-smelling gas may be found in the peri- 
 toneal cavity. When perforation of viscera has occurred, 
 various materials may be got there. 
 
 The intestines are distended with gas, their walls being 
 cedematous, softened, and infiltrated. The stomach is often 
 small and contracted. In extensive and severe peritonitis, 
 the abdominal muscles may be softened and somewhat 
 degenerated. 
 
 Peritonitis may be more or less general or localised. 
 The three seats in which localised attacks mostly occur are 
 the region of the diaphragm, that of the caecum (especially 
 its outer side), and the pelvis. It is rare to find the area 
 of the small intestine the seat of these circumscribed 
 
 ii 
 
304 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 attacks. In these three regions, the type of inflammation 
 is usually healthy, and recovery is most frequent from them, 
 either spontaneously or after operation. These local attacks 
 of peritonitis may cause thickenings and adhesions, collec- 
 tions of serum or pus. Thus abscesses may be formed in 
 the pelvis, iliac fossae, lesser omental sac, hypochondrium, 
 subphrenic region, etc. 
 
 A general peritonitis may succeed the circumscribed 
 form, but not often. Adhesions prevent the spread, or 
 it may remain localised because of some special local 
 peculiarity. Some think that the omentum helps to pre- 
 vent the spread of inflammation from below upwards, and 
 Mikulicz believes that the transverse colon prevents its 
 extension from above downwards. 
 
 Symptoms. — The symptoms of acute peritonitis vary 
 according to the cause, its seat and extent, the condition 
 of the patient, etc. 
 
 Local. — Pain is one of the most marked symptoms. It 
 usually begins in one region, and then spreads rapidly, though 
 it may sometimes be at first referred to the region of the 
 solar plexus. It may vary at different spots, being described 
 as hot, cutting, boring, darting, burning, etc. Exacerba- 
 tions occur from time to time, owing to movements of the 
 bowel. It is aggravated on exertion. The sufferer usually 
 lies on the back with the thighs well flexed. Abdominal 
 breathing is lessened. The abdomen is very sensitive to 
 touch, and becomes rigid. Where perforation of the gut 
 has occurred, the belly wall tends to sink in towards the 
 spine. 
 
 As the inflammation extends, the pain, hyperaesthesia, 
 and contraction of the abdominal wall pass away, and the 
 tenseness of the latter is merely due to the distension of 
 the intestines. This change is especially marked when 
 sepsis develops. If septic phenomena occur very early in 
 the case, there may be no hyperaesthesia or pain whatever. 
 
 Disturbances occur in the alimentary tract. There is 
 
 !\ 
 
ACUTE PERITONITIS, 
 
 305 
 
 loss of appetite, thirst, nausea, vomiting. The latter 
 varies in degree in different cases, and sometimes may be 
 absent. 
 
 The tongue is furred, often being red and irritable, 
 gradually becoming dry. There is often a disagreeable taste 
 in the mouth, while the breath is offensive. Eructation 
 of gas is common. Constipation is a common feature, 
 mainly owing to paralysis of the bowel, though sometimes 
 diarrhoea is met with. Irregular contractions of the intes- 
 tine take place in the early stages particularly, causing 
 gurgling sounds. Jaundice is sometimes present. Mic- 
 turition may at first be frequent, but later there may be 
 retention. The urine is diminished in quantity ; sometimes 
 there is suppression. 
 
 Hiccough is often present. The respirations often get 
 frequent and shallow. Marked dyspnoea often exists, and 
 the heart's action may be very rapid. The changes in the 
 respiration and circulation are due to the general condition, 
 to the pain from the peritonitis, to action of the inflamma- 
 tion on the diaphragm, and to the pressure of the distended 
 intestines. In some cases they may be aggravated by the 
 development of pleurisy, pneumonia, or pericarditis. 
 
 General symptoms. — Rigors may mark the invasion stage 
 of the attack, but they are often absent. The febrile 
 phenomena are very variable, and they are no sure guide to 
 the extent or gravity of the affection. Treves points out 
 that in some cases the temperature moves steadily upwards ; 
 in others, steadily downwards ; in others, a fairly even line 
 of high fever may be followed ; while in others, a normal 
 or subnormal course may be marked. The occurrence of 
 diarrhoea or of a sudden perforation is usually marked by 
 a drop in temperature. Sometimes the temperature may 
 fall only gradually, especially where the bowels continue to 
 keep open. When the bowels cease to act, it tends to rise 
 again after the fall. When the perforation occurs slowly, 
 it may rise at first and then sink. Persistent subnormal 
 20 
 
 '•■ i(; 
 
3o6 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 temperature makes the prognosis very bad. It is often 
 found where general sepsis is present. The most marked 
 febrile signs occur with a plastic peritonitis, or where there 
 is a localised pus collection. 
 
 Where the peritonitis is due to hernia, the temperature 
 as a rule remains low. Before death in marked septic 
 cases, the temperature usually sinks ; though, sometimes, it 
 may rise very high. 
 
 When gangrene of the bowel is present, the temperature 
 is usually high. When there is disease in the appendix, it 
 is generally high. 
 
 The />u/se increases in rapidity, usually varying from 120 
 to 160. It is at first full, and bounding, becoming small, 
 hard, wiry, or thready ; sometimes very soft and irregular. 
 
 The face has an anxious or pained expression, and the 
 features appear sunken and pinched, dark areolae being 
 around the eyes. There may be a feeling of great prostra- 
 tion and restlessness. There may be more or less cyanosis. 
 Often sleeplessness or headache is complained of; some- 
 times delirium or stupor. The mind usually remains 
 bright and clear to the end. As death approaches, the 
 extremities get cold, and the skin covered with a clammy 
 sweat. 
 
 Physical signs. — The abdomen early becomes rigid, and 
 it may be slightly depressed ; in perforation cases, markedly 
 so. Abdominal respiration is slight. The surface is tender 
 to the touch. Later, meteorism develops as the abdominal 
 walls relax. The distension of the abdomen is symmetrical 
 generally, but not always. Sometimes a transverse groove 
 can be made out in the epigastrium. In very muscular 
 persons there may be little enlargement. Intestinal move- 
 ments are sometimes visible. 
 
 On percussion the note is tympanitic, and varies in 
 different parts. If the distension is extreme, the sound is 
 muffled and toneless. The splenic and hepatic dulness 
 are lessened. Small quantities of fluid cannot be made out. 
 
 f 
 
 I \ 
 
 !\ 
 
ACUTE PERITONITIS. 
 
 307 
 
 Where there is a considerable collection, dulness may be 
 got on percussion in the dependent parts, varying on change 
 of posture. Where there is encysted fluid, the dulness is 
 unaffected by change in position. Fluctuation may be 
 obtained if there be a sufficient quantity of fluid in the 
 peritoneum. On auscultation, friction sounds may some- 
 times be heard ; also, movements of intestinal contents. 
 
 On examination of the chest, the heart is found dis- 
 placed upwards and to the left, i.e. when the abdomen is 
 distended, and there is often dulness at the base of the 
 lungs. 
 
 Course and terminations. — The patient may die. Or 
 recovery may gradually take place, where t le inflammation 
 has not been too severe or extensive. Sometimes a chronic 
 condition may develop, the temperature remaining high 
 and irregular. Fluid collections may remain, and a con- 
 dition of pyaemia may develop, or the collection may burst. 
 A condition of wasting may supervene, and death may 
 follow. Extensive adhesions may develop, giving rise to 
 much after-trouble. 
 
 Differential diagnosis. — Various conditions may be mis- 
 taken for acute peritonitis. 
 
 1. There are certain abdominal neuroses which may lead 
 to an error in diagnosis. These may give rise to such 
 symptoms as pain, a rigidity of the walls, sensitiveness to 
 touch, meteorism, vomiting, constipation, diarrhoea. 
 
 2. Myalgia, hypersesthesia, or localised inflammations in 
 the abdominal wall. 
 
 3. Colic, the passage of renal and biliary calculi. 
 
 4. Extreme tympanites and pain in low febrile condi- 
 tions, e.g. typhoid. 
 
 5. Marked enteritis. 
 
 6. Extraperitoneal rupture of a tubal pregnancy or of an 
 aneurism; haematocele. 
 
 7. Acute pleurisy or pneumonia may at first simulate 
 peritonitis. 
 
AFFECTIONS OF PERITONEUM, ETC. 
 
 Prognosis. — The worst forms are those due to perfora- 
 tion and severe septic infection. Very serious are those 
 associated with nephritis. In infancy peritonitis is very 
 fatal. A poor condition of health is very unfavourable. 
 The more localised the affection, the greater is the chance 
 of a favourable issue. Very marked tympanites, bad 
 vomiting, the passage of blood from stomach or bowel, 
 continuous hiccough, high temperature, early collapse, 
 rapid, feeble, and irregular pulse, a comatose condition, are 
 indications which make the prognosis very grave. Com- 
 plications of the nature of pleurisy, pneumonia, or peri- 
 carditis greatly increase the risks. 
 
 Treatment. — Complete rest with the knees flexed over a 
 support is necessary. The chest and arms should be covered 
 in a woollen garment. 
 
 As little food as possible should be given by the mouth. 
 For the severe thirst, iced milk and soda-water may be 
 employed, but often hot water or hot tea may be preferred. 
 The continued sucking of ice is to be avoided. Sometimes 
 a good draught, even if it be followed by vomiting, relieves 
 thirst for some time. The mouth may be rinsed out from 
 time to time with glycerin and water, or with eau de 
 Cologne and water. 
 
 l^he patient should be fed by small enemata of pepton- 
 ised beef-tea, or meat-extract, a little brandy being added. 
 These should not be diluted. To add water to the body, 
 separate injections should be given. Irritability of the 
 rectum may be somewhat relieved by occasional flushings 
 with water or weak cocain solutions. When the sphinc- 
 ter relaxes, the enemata must be stopped, but when this 
 occurs the patient is generally beyond hope. When there 
 is diarrhoea, feeding must be tried by the mouth, and very 
 often in such cases it can be carried out. 
 
 Saline aperients may be given at the onset of peritoneal 
 inflammation, but they must not be used when general 
 peiitonitis is established, especially when a septic condition 
 
 / 
 
ACUTE PERITONITIS. 
 
 309 
 
 is recognised. And, of course, they are not to be admin- 
 istered by the mouth when any intestinal obstruction exists. 
 Enemata m'^y be given in the hope of clearing the lower 
 bowel. 
 
 Whenever there is collapse, alcoholic drinks, especially 
 champagne and brandy, must be given by the mouth or by 
 enemata. When the condition is septic, very large quan- 
 tities must be given, e.^. 15 to 20 oz. of brandy in twenty- 
 four hours. 
 
 Opium should be used as little as possible. In the eavly 
 stages it is generally necessary, and may be given as an 
 injection of morphine. Some prefer to administer laudanum 
 by the mouth along with the aperient dose, It may often, 
 at this stage, avert the ill-effects of shock. The indication 
 should be pain, and not mere discomfort and distress. In 
 septic cases it is not necessary. 
 
 In advanced cases the hypodermic injection of strychnine 
 often gives the patient much relief. 
 
 Calomel, or enemata containing turpentine, sometimes 
 relieves meteorism. But the passage of a long rubber tube 
 per rectum is generally more efficacious. 
 
 Nausea and vomiting may often be relieved by champagne, 
 creabote, or by hydrocyanic acid and bismuth. For hic- 
 cough, sedatives may be given, mustard applied to the 
 epigastrium, or in bad cases chloroform administered. 
 
 Local applications to the abdomen often give great relief. 
 In the early stages, either cold or hot compresses may be 
 employed with turpentine or anodynes. The patient may 
 be allowed the choice. Later, only hot applications are to 
 be used. 
 
 Blood-letting by leeches or venesection may be tried at 
 the onset of an attack, if the patient be robust and full- 
 blooded. 
 
 Operative measures. — Operative treatment has not yet 
 been established on a satisfactory basis. When suppuration 
 is localised, e.g. around the vermifo' a appendix, in the 
 
 
 yy 
 
 
310 
 
 AFFECTIONS OF PERITONEUMy ETC, 
 
 pelvis, after injury or perforation, or under the diaphragm, 
 the collection should be opened, stuffed with iodoform 
 gauze for twenty-four hours, and then irrigated daily with 
 an antiseptic lotion, e.g. iodoform emulsion. If advisable, 
 gauze may also be used for some days. 
 
 The treatment of widely diffused suppurative peritonitis 
 by operation is very unsatisfactory. 
 
 The peritoneum is to be opened, and any recognised 
 source, e.g. gangrenous bowel, appendicitis, etc., to be 
 attended to. The cavity must then be thoroughly irrigated 
 with warm saline solution, as described on p. 276, and then 
 drained. The most thorough washing may not remove all 
 the pus from the cavity ; portions are apt to be caught 
 among folds of bowel. 
 
 When there is much plastic peritonitis binding the in- 
 testines together it may be necessary to separate adhesions, 
 to get at the source of the infection, or to let out the pus, 
 and bleeding may be started. 
 
 It is not wise to do too much in this direction, even to 
 find the source of trouble. When irrigation and drainage 
 are not possible in some of these cases, iodoform should be 
 dusted among the bowels, after the peritoneum has been 
 mopped with gauze-pads. 
 
 If the cause be a perforation, it is generally best not to 
 interfere with the adhesions, for they may be in process of 
 closing the opening \ all that should be done is to wash out 
 free pus and debris. 
 
 II. Chronic Peritonitis. 
 
 This is met Wxch localised or diffuse, and occurs in many 
 varying conditions. It may follow an acute attack. It may 
 be associated with the irritation of cirrhosis or carcinoma of 
 the liver, cancer or ulceration of stomach or intestine, old 
 hernias, ascites, tapping of fluid in abdomen. It may spread 
 from localised inflammations, e.g. peri-hepatitis. It is said to 
 
 i\ 
 
CHRONIC PERITONITIS. 
 
 3" 
 
 follow cold or exposure. It may occur in chronic nephritis, 
 gout, rheumatism, alcoholism, lead-poisoning, etc. It may 
 be due to tubercular or cancerous infection of the peritoneum 
 i^vide p. 320). 
 
 Morbid anatomy. — Great variations are found. There 
 may be thickenings of the peritoneum, adhesions, matting to- 
 gether of viscera ; serous, seropurulent, or purulent effusions, 
 usually more or less circumscribed ; caseation or calcareous 
 degeneration of inflammatory products may be found, and 
 pigment deposit ; distortion, displacement, or obstruction of 
 viscera may be brought about ; the intestinal wall may be 
 wasted, though the stomach is oftener thickened. 
 
 Symptoms. — These are very varied. If the condition has 
 developed fro.n an acute attack, there is a gradual alteration 
 in the type of the symptoms noticed. 
 
 If no acute attack precedes it, the onset is usually very 
 insidious. There may be uneasiness ; dull or irregular 
 pains, sometimes somewhat aggravated ; constipation, diar- 
 rhoea, colic, flatus, vomiting, dyspepsia; there may be 
 increased discomfort or pain on movement, or on palpation 
 of the abdomen. Owing to the pressure of inflammatory 
 thickenings on various parts, various phenomena may 
 supervene, e.g. jaundice, ascites, thrombosis, oedema of the 
 legs, albuminuria, etc. 
 
 The temperature shows great variations. It may not be 
 elevated at all, or it may be very irregular. There may be 
 gradual weakening and wasting, hectic, increased pulse, 
 dryness of skin. The health of the patient may vary greatly 
 from time to time. 
 
 Physical signs. — The abdomen may be enlarged, partly 
 owing to the fluid in the peritoneal cavity, or, partly, 
 to gas in the bowels. The enlargement may be uniform, 
 but it iL- often irregular. On palpation, there may be 
 tenseness or a uniform doughy feeling ; or irregularities 
 may be felt, e.g. nodulations. In percussion, free fluid 
 may be recognised, but usually it is found to be localised ; 
 
 Ji 
 
 .; \X:. 
 
312 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 generally, irregular areas of dulness and resonance are 
 distinguishable. 
 
 Fluctuation may often be got in fluid collections, and 
 friction-fremitus may occasionally be made out. Change of 
 position, as a rule, causes little alteration in the physical signs. 
 
 Treatment. — Rest in bed for a long period is often advis- 
 able. Good surroundings, change of air, careful dieting, 
 cod-liver oil, wine, iron, quinine, and other tonics are of 
 great value. The iodide of iron, or potassium, may be 
 given inwardly. Counter-irritants to the abdomen are good, 
 e.g. iodine, blisters ; the inunction of mercury ointment is 
 valuable. Pressure by means of cotton wool and a bandage 
 should be employed. Collections of serous fluid may be 
 tapped. Purulent gatherings may be treated in the ordinary 
 surgical manner. 
 
 III. Acute Pelvic Peritonitis (Pelveo-Peritonitis, 
 
 Perimetritis). 
 
 This is a local peritonitis within the cavity of the pelvis. 
 Much that has been described in connection with general 
 peritonitis may be applied here, but it is necessary to make 
 special reference to the localised affection. All varieties 
 are met with in the pelvis, e.g. simple, adhesive, serous, 
 purulent. 
 
 Etiology. — The great majority of inflammations in the 
 pelvic peritoneum are due to infection by micro-organisms 
 or their products. The poison may enter by way of the 
 genital tract, by the bowel, or by the bladder. The first of 
 these is the most frequent path, and it is easy to understand 
 why this should be so. The Fallopian tubes communicate 
 directly with the peritoneum ; the uterus is continually 
 being subjected to injury in connection with child-birth, 
 and is consequently exposed to infection from the exterior. 
 In tabulating the chief sources of pelvic inflammation we 
 may particularly note the following : — 
 
 I \ 
 
ACUTE PEL VIC PERITONITIS. 
 
 313 
 
 1. Imperfect precautions to ensure asepsis in performing 
 operations on the genital tract, bladder, and rectum. 
 
 2. Abortion and child-birth. Here the infection may 
 spread along the Fallopian tube, or through the tissues, 
 either directly by the lymphatics, or by the blood vessels. 
 
 3. Gonorrhoea and latent gonorrhcea in the male are 
 generally regarded as important sources of infection. At 
 present, it is, perhaps, safer to say that pelvic peritonitis is 
 very often associated with these conditions than that it is 
 due to the direct action of the gonococcus. Very probably 
 the infection is often due to pyogenic cocci, which have 
 formed a nidus in the discharges due to the inflammation 
 set up in the lower genital tract {pide p. 155). 
 
 4. Extension from inflammatory areas, e.g. ^ubes, uterus, 
 ovaries, cellular tissue. 
 
 5. It is often associated with new growths, e.g. ovarian 
 tumours, fibroids, carcinoma, tubercle ; and with swellings, 
 e.g. haematocele. 
 
 6. Severe chills, especially during menstruation, are be- 
 lieved to occasionally cause pelvic peritonitis. 
 
 7. Sexual excess is described by some. This must be 
 regarded as very doubtful. 
 
 8. Traumatism, e.g. the forcing of fluids along the Fallo- 
 pian tubes by careless irrigation of the uterus. 
 
 Ssnnptoms. — The pulse is first rapid, full, bounding ; later, 
 small, hard, wiry, or thready ; in bad cases, soft and irregu- 
 lar. The temperature rises early, and continues more or 
 less elevated. Often the onset is marked by rigors. Pains 
 develop of a burning, cutting, darting, or boring nature. 
 There is nausea, vom.iting, constipation • sometimes diar- 
 rhoea. It is rare to find such symptc/ms as have been 
 described in connection with severe general peritonitis, 
 unless the local condition spreads and becomes diffuse. 
 When pus collections have formed, the symptoms are those 
 of abscess. Pus may tend to open through vagina, bowel, 
 bladder, or through the abdominal wall. 
 
 
 
 i ! 
 
 
 Mil 
 
 ! 
 
s 
 
 314 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 Physical signs. — The abdomen is early rigid. Afterwards 
 it may be distended. Both legs are drawn up. The belly 
 is tender or painful in its lower part. On bimanual exam- 
 ination, the vagina is hot and sensitive. When there is 
 free fluid in the pelvis, an indistinct boggy fulness may be 
 made out. When consolidation has taken place in it, a 
 hard mass like plaster of Paris is felt behind, and at the 
 sides of the cervix ; sometimes around it. In other cases, 
 masses of serous fluid may be encysted, and are felt in the 
 middle line pushing the uterus forward ; sometimes in front 
 of the uterus, when this organ has been retroverted ; some- 
 times on either side behind the broad ligament. 
 
 After an acute attack has passed off, various conditions 
 are found, e.g. thickenings, adhesions, displacement of uterus 
 or appendages. There is usually considerable tenderness on 
 examination. 
 
 Treatment — General. — The patient should be placed at 
 rest in bed. Milk and potash or soda-water, peptonised 
 beef-tea and beef-jelly are to be given by the mouth. Alco- 
 holic stimulants are to be given if the patient is weak ; if 
 pus be present, large quantities may be required. Pain is 
 to be counteracted with hypodermics of morphine. Quinine 
 is of use as an antipyretic. Early, castor-oil or saline 
 aperients are of great value. 
 
 When convalescent, the patient should be given plenty of 
 nourishing and easily digested food j the bowels should be 
 kept regular. Iron, wine, and other tonics are to be given. 
 The patient should carefully avoid exertion and exposure to 
 cold or damp. 
 
 Local. — Cold compresses over the lower abdominal region 
 are valuable in the early stages. But if the patient does 
 not like them, hot fomentations can be applied every two 
 hours. Hot vaginal douches are valuable, but they often 
 distress the patient. Encysted serous fluid, which does not 
 get absorbed, may be tapped, usually through the fornix 
 vaginae, with aseptic care. Purulent collections must be 
 
 I \ 
 
CHRONIC PELVIC PERITONITIS. 
 
 315 
 
 opened and treated in the manner described already, either 
 through the vagina or abdominal wall. In the convalescent 
 stage, the patient should wear a flannel binder for months. 
 
 IV. Chronic Pelvic Peritonitis. 
 
 I have already described the chief changes found, in 
 describing chronic peritonitis in general. In the pelvis, 
 thickenings, adhesions, and displacements of the uterus 
 and appendages are produced. The ureters may sometimes 
 
 Fig. 82. — Peritonitic adhesions behind the uterus, matting together 
 the tubes and ovaries on both sides, and obliterating the pouch 
 of Douglas. 
 
 be constricted. The bladder may be interfered with by 
 adhesions or by effusions. The bowel functions may be 
 affected. 
 
 Symptoms. — These vary greatly. Where an acute attack 
 has preceded the chronic trouble there is a history of a 
 gradual change from the acute symptoms. In other cases, 
 the affection begins insidiously and without marked symp- 
 toms. Sometimes there may be a history of pain, perhaps 
 beginning in connection with a menstrual period. In some 
 cases there is a history of a slight attack of pain with fever. 
 
 '•'jit 
 
 I I 
 
 I 
 
V 
 
 3i6 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 Various degrees of pain may be met with — dull, sharp, 
 aching. It is often worse after exertion, at menstruation, 
 during coitus, or at defaecation. There may be menorrhagia, 
 metrorrhagia, or irregular menstruation. Sterility is com- 
 mon. The health of the patient is below par, and she often 
 has various reflex nervous disturbances. In many cases she 
 develops marked neuroses. It is important, therefore, to 
 note that the suffering of which the patient complains may 
 be often very largely neurotic, non-commensurate with the 
 amount of pathological change in the pelvis. 
 
 The bladder functions are not often disturbed. But 
 there may be irritability, tenesmus, dysuria, or incontinence. 
 These symptoms may be due to the pressure of effusions, or 
 of a displaced uterus, to the traction of peritonitic bands, 
 or to inflammation in the bladder wall. The circulation 
 and innervation of the gut may be affected and its peristalsis 
 interfered with. Rectal catarrh, constipation, diarrhoea, 
 flatulence are met with. Rarely, ileus results from inter- 
 ference by adhesions. 
 
 Treatment. — The general means taken should consist of 
 measures to improve the general health and to strengthen 
 the nervous system. The stomach and bowels should be 
 kept in good order. The patient should rest for a time from 
 hard work. Coitus should be avoided. If the patient ic very 
 neurotic, a course of Weir Mitchell treatment is valuable. 
 
 Locally, the hot douche, hot hip-baths, vaginal tampons 
 soaked in glycerin or in ichthyol and glycerin, and blis- 
 tering above Poupart's ligament may be employed. The 
 uterus should be curetted if there be endometritis, and any 
 inflammation about the cervix should be treated. 
 
 Schultze and others recommend breaking down of old 
 adhesions by bimanual manipulations under chloroform. 
 This method is dangerous, however, and is not to be 
 advocated. 
 
 Recently, anterior or posterior colpotomy has been em- 
 ployed, the adhesions being broken down, or ligatured and 
 
 \' 
 
TUBERCUL A R PERITONITIS. 
 
 3»7 
 
 divided after the peritoneum is opened, the uterus being 
 pulled down with forceps to bring the adhesions within 
 reach. 
 
 V. TuHERcur.AR Peritonitis. 
 
 This affection is .net with under three different sets of 
 conditions. It may appear as part of a general miliary 
 tuberculosis. It may be a localised development in con- 
 nection with ulceration of the intestine, beginning in 
 thickenings on the peritoneal surface over the ulcer. 
 
 It may be a widespread affection in the peritoneum, of a 
 chronic or subacute nature, often associated with ulceration 
 of the bowel, sometimes with enlargements in the mesenteric 
 glands. Tubercular affection of the Fallopian tubes and 
 uterus may be present. Pulmonary trouble very often exists. 
 
 Pathological changes. — These present varied appearances. 
 When acute miliary tuberculosis exists, the peritoneum is 
 studded with tubercles in various stages of development, 
 usually believed to be most numerous in the flanks and on 
 the diaphragm, less marked on the intestines. As the pro- 
 cess gets more chronic, adjacent granulation masses tend 
 to blend. There is abundant citron-coloured ascitic fluid 
 produced, sometimes blood-stained, rarely seropurulent. 
 Adhesions are usually slight. In other cases ascitic fluid 
 may be encysted in one or more loculi by means of 
 adb sions. 
 
 In another class of cases there is considerable fibroid 
 change, the tuberculous process tending towards improve- 
 ment. Sometimes this is found as large scattered tubercles, 
 there being no adhesions nor ascites. More commonly 
 there are marked adhesions between the bowels, the omen- 
 tum being often in a crumpled, irregular mass below the 
 stomach. The mesentery may also be contracted and 
 thickened. 
 
 When the tuberculous products break down, different 
 appearances are caused. Sometimes the matted intestines 
 
 
 
 \\i 
 
 I 
 
■v.. 
 
 ^ 
 
 318 
 
 AFFECTIONS OF PERITOAEUM, ETC. 
 
 are covered with a mass of grey or yellow adhesive material 
 with caseous masses ; on breaking through it, loculi may be 
 seen, containing clear fluid, caseous matter, chocolate-like 
 fluid or pus. The bowel may be perforated at points by 
 the breaking down of ulcers. Adjacent coils of gut may 
 communicate, or a fistula may discharge at the umbilicus. 
 
 Sometimes there may be extensive suppuration, diffused 
 or localised. Occasionally the mesenteric glands are en- 
 larged, but not often in bad cases of peritonitis. They may 
 form a large irregUiar mass, several large masses, or a series 
 of small isolated swellings. 
 
 Intestinal obstruction may result from the adhesions of 
 tubercular peritonitis. 
 
 Symptoms and physical signs. — These vary greatly. 
 Sometimes the trouble begins with rigors ; sometimes there 
 is fever. Usually, there is dyspepsia, diarrhoea, constipa- 
 tion, and pains in the abdomen. The onset, in the majority 
 of instances, is gradual. The abdomen tends to enlarge, and 
 the patient loses flesh. As the case advances there is an 
 irregular febrile condition, and hectic may develop. There 
 is generally malaise. Often sweating is profuse. There 
 are generally relapses and remissions. There may be me- 
 teorism, found in varying degrees. There may be general 
 tympanites, or it may be combined with dulness due to free 
 ascitic fluid. Or areas of resonance may alternate with 
 patches of dulness, the latter being due to fluid collections 
 or to thickened masses of bowel, omentum, or adhesions. 
 The umbilicus is often protruded. On palpation, the abdo- 
 men is often tender, over the whole surface or in areas. 
 Enlargements due to affection of the mesenteric glands may 
 be felt. 
 
 Differential diagnosis. — Tubercular peritonitis may be 
 mistaken for a variety of conditions, e.g. cyst of mesentery 
 or liver; enlargements of kidney; malignant disease in 
 abdominal viscera ; perityphlitic abscess ; internal hernia ; 
 tumours of the abdominal wall ; enlarged mesenteric glands 
 
 / ( 
 
 I \ 
 
TUBERCULAR PERITONITIS. 
 
 319 
 
 have been diagnosed as floating kidney, enlarged spleen, or 
 as various kinds of tumours. 
 
 Treatment. — The general treatment for tubercular disease 
 is to be carried out. Locally, the application of a counter- 
 irritant, e.g. tincture of iodine or mercury liniment, is valu- 
 able, and also the inunction of ointments of mercury. 
 
 Operative measures are to be employed in certain cases. 
 When there is free serous fluid or a large encysted quantity 
 in the abdomen, the latter should be opened, and the fluid 
 removed. The incision should then be closed. Such a 
 procedure is very often followed by cure. 
 
 When the fluid is purulent, the peritoneal cavity may be 
 irrigated with warm saline solution, and drained for twenty- 
 four or forty-eight hours with iodoform gauze. If drainage 
 be kept up too long in these cases a sinus is apt to form, 
 or a faecal fistula, as a result of pressure of the drain on the 
 bowel. 
 
 When adhesions and thickenings are prominent, there 
 being little or no fluid, the results of opening the peri- 
 toneum are not so satisfactory, though undoubted benefit 
 may result in some cases. In operating, care must be 
 taken not to open the gut. If, owing to adhesions, it be 
 impossible to cut into the peritoneum by one incision, 
 others should be made in the hope of gaining entrance 
 where no adhesions exist. 
 
 The latter are usually most marked below the umbilicus. 
 A drainage-tube should not be placed among matted coils 
 of intestine. If many adhesions have been broken through, 
 however, it may be necessary to drain. 
 
 Operative procedures should not be carried out when 
 there is acute general miliary tuberculosis or very advanced 
 tubercular disease in other organs of the body. 
 
 The following suggestions have been made to explain the 
 method of cure in these operative cases, namely, that it is 
 due to the admission of light or of air ; to the removal of 
 the fluid ; to the escape of the ptomaines and toxins pro- 
 
 I 
 
 
 ,5 
 
 '.7, 
 
 i 
 
 
 
320 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 duced by the microbes ; to modifications of intra-abdominal 
 pressure, leading to an improved circulation and to a more 
 active absorption. 
 
 Mere puncture seldom brings about an improvement. 
 
 VI. Malignant Peritonitis. 
 
 This is not very common, and is generally cancerous. In 
 the great mass of cases it is secondary to malignant disease 
 in the alimentary canal, especially the stomach, liver, 
 pancreas, retroperitoneal glands, female genitals. It may 
 be developed by extension or by secondary deposit. It 
 may spread from one serous surface to another with the 
 formation of adhesions. The chief pelvic causes are 
 malignant disease of the ovaries and rupture of papillo- 
 matous cysts. 
 
 Peritoneal cancer is most often scirrhous in type, some- 
 times encephaloid or colloid. The disease is found in 
 diffused nodules or masses, which tend to become umbili- 
 cated. The omentum may be drawn up in a mass. There 
 is generally some chronic peritonitis, with more or less 
 effusion, often bloodstained. It may spread to various 
 structures and may interfere with the intestinal tract, 
 narrowing it, or causing ileus. In the colloid form, the 
 viscera may be covered in thick, gelatinous masses. 
 
 Symptoms and physical signs. — Great variations are 
 found. They are due to the general decay in health, the 
 interference with various functions, and to associated 
 peritonitis. 
 
 In the early stages there are only obscure and indefinite 
 symptoms. Abdominal pains develop, and various disturb- 
 ances of the alimentary tract. There is ascites and some- 
 times jaundice. Cachexia develops. Sometimes marked 
 anaemia from loss of blood in the peritoneal cavity. Some- 
 times there is considerable fever, but generally there is little 
 or no pyrexia, and of an irregular type. There is tenderness 
 
 • '\ 
 
PELVIC CELLULITIS. 
 
 321 
 
 and resistance on palpation. Fluid may easily be made out 
 on percussion. Irregular masses may be felt, and enlarge- 
 ments of groups of glands. 
 
 Treatment. — The strength must be kept up and the 
 various symptoms treated. It may be necessary to tap 
 the abdomen from time to time. 
 
 VII. New Growths in the Peritoneum. 
 
 Tuberculosis and malignant disease have already been 
 described. Hydatids sometimes produce large swellings. 
 Lipomata, myxomata, and myxo-lipomata sometimes develop 
 to a great extent retroperitoneally. Cysts of various kinds 
 are found, e.g. dermoids, serous, colloid ; some of these 
 are probably due to the breaking down of lipomata and 
 myxomata. Fibromata are rare. Malignant adenomata 
 sometimes develop from remains of the Wolffian body. 
 
 Treatment. — Cysts may sometimes be evacuated. Solid 
 tumours may sometimes be removed, if small or somewhat 
 pedunculated. Shepherd has recently reported a successful 
 case of removal of a very large myxo-fibroma from the 
 mesentery, eight feet of small intestine being taken away as 
 well. 
 
 PELVIC CELLULITIS (PARAMETRITIS). 
 
 Nature.- -This is an inflammation, acute or chronic, 
 affecting a portion ^ the pelvic cellular tissue. The most 
 common seats are the bases of the broad ligaments and the 
 utero-sacral folds. There is usually some associated peri- 
 tonitis over the seat of the cellulitis, just as in peritonitis 
 there is more or less underlying cellulitis. 
 
 Etiology. — The chief cause, probably the only direct 
 
 cause, is germ infection. It is doubtful if simple injury will 
 
 be followed by cellulitis. Traumatism, however, plays an 
 
 important part in the causation of pelvic cellulitis, namely, 
 
 21 
 
 
 .;;;]■ 
 
 
 ■m 
 
 
 f! 
 
 ii 
 
 t 
 
 r^'^™ 
 
V, 
 
 322 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 by affording an area which allows the germs an entrance 
 ground. 
 
 The special conditions with which it is associated are the 
 following : — 
 
 1. Abortion, premature and full-time labours, infection 
 entering through the raw or bruised surfaces, produced as 
 a result of imperfect asepsis. 
 
 2. Operative measures on the genital tract, bladder, or 
 rectum, in which thorough asepsis is not obtained. 
 
 3. Diseased conditions in bladder or rectum, whereby 
 infection of the cellular tissue occurs. 
 
 4. Secondary to peritonitis. 
 
 5. It is said that it may result from a severe chill during 
 menstruation. 
 
 Pathology. — At first there is an exudation. This may 
 become quickly absorbed, or only a portion may be 
 absorbed, the rest remaining as a thickening. This may 
 gradually disappear, followed by shrinkage and cicatrisation. 
 Or pus may form and an abscess be produced. This may 
 burrow in various directions, and may open in the following 
 ways : — 
 
 1. Through the bladder, rectum, vagina, or urethra. 
 
 2. Through the perineum. 
 
 3. Through the abdominal wall. 
 
 4. Through the obturator, sacro-sciatic, or saphenous 
 openings. 
 
 5. Through the lumbar region near the kidney. 
 
 6. Rarely into the peritoneal cavity. 
 
 Exudations spread by lymphatics and directly through the 
 tissues. According to Konig there are lines of cleavage so 
 arranged as that fluid in the upper portion of the broad 
 ligament extends out to the pelvic wall, then along the 
 psoas-iliacus, sinking below the brim. Fluid in the lower 
 and anterior portion passes out to the side pelvic wall 
 Ir'erally, and runs along the round ligament to the abdomi- 
 nal wall, thence by Poupart's ligament to the iliac fossa. 
 
 ,!X 
 
PELVIC CELLULITIS. 
 
 3«3 
 
 Fig. 83. — Sagittal lateral section 
 of the pelvis, showing a large 
 inflammatory collection in the 
 right broad ligament. 
 
 When in the lower and posterior part it burrows around the 
 
 pouch of Douglas and then follows the course first men- 
 tioned above. 
 
 When the pus has discharged and healing has taken 
 
 place, there is more or less 
 
 contraction and cicatrisation 
 
 in the cellular tissue. 
 Cellulitis usually leaves more 
 
 or less marked traces behind 
 
 it, the most marked of which 
 
 are displacements. The most 
 
 common alterations are found 
 
 in the uterus. This organ 
 
 may be lateriverted, when the 
 
 inflammation has taken place 
 
 in a broad ligament. When 
 
 it has existed in the utero- 
 
 sacral ligaments, the lower 
 
 portion of the organ is fixed and drawn somewhat upward 
 
 and backward, the fundus bending forward ; this condition 
 
 being known as pathological 
 anteflexion. 
 
 The ovaries and tubes may 
 be more or less displaced. 
 The bladder may sometimes 
 be altered, and occasionally 
 the rectum may be affected. 
 
 Symptoms — {a) In acute cases. 
 — There is often a rigor at the 
 onset. There is pain in the 
 Fig. 84.— Inflammatory exuda- pelvis and, it may be, in the 
 tion in the cellular tissue lower abdominal region. Pulse 
 
 behind the pouch of Douglas , ^ , . , 
 
 at the side of the rectum. ^^^ temperature are raised. 
 
 When there is marked exuda- 
 tion the patient may lie with one leg drawn up. There 
 may be constipation, painful defaecation, and dysuria. 
 
 ili-'ii 
 
 
3H 
 
 AFFECTIONS OF PERITONEUMy ETC, 
 
 In slight cases the patient may complain only of slight 
 uneasiness. 
 
 {h) In chronic cases. — The symptoms are much the same 
 as in chronic pelvic peritonitis {vide p. 325). 
 
 Physical signs. — In the early stages nothing definite may 
 be made out. A little fulness or tenderness may sometimes 
 be recognised. As consolidation occurs in the effusion, a 
 hard mass may be felt. When in the broad ligament, if it 
 be of any size, it fixes the uterus, and pushes it somewhat 
 towards the opposite side and bulges down the lateral 
 fornix. If the utero-sacral folds are affected, the cervix 
 
 is felt fixed, and there 
 is a thickened mass on 
 each side behind, most 
 easily felt through the 
 rectum. In other cases 
 the thickening may be 
 felt at the side of the 
 bladder, vagina, or rec- 
 tum, reaching above 
 Poupart's ligament, in 
 the iliac fossa, etc. 
 There is tenderness on 
 pressure. Sometimes, 
 on flexing and abduct- 
 ing the thigh, pain runs 
 down the leg, owing to the implication of the lumbar and 
 iliac glands and of the tissue around the psoas-iliacus 
 muscle ; there may thus be a simulation of hip-joint disease. 
 It is very rare to find any deposit between the cervix and 
 bladder. When fluid is present it may often be recognised 
 as a cystic mass, but sometimes it may be thought to be 
 •solid. Sometimes pus may exist in the centre of thick 
 solid masses, and may be very difficult to make out ; it 
 may often be felt as a boggy mass. 
 
 In old-standing cases various cicatrices and displace- 
 
 FiG. 85. — Coronal section of pelvis, in 
 which a chronic cellulitis in the right 
 broad ligament is drawing the cervix 
 towards the right s-ide. 
 
 t\ 
 
PELVIC CELLULITIS. 
 
 395 
 
 ments are found, the uterus being drawn towards the 
 affected side. 
 
 Differential diagnosis between pelvic peritonitis and 
 cellulitis. — In some cases this cannot be made out 
 clinically. Between marked types of each the following 
 distinctions may be drawn : — 
 
 Pelvic Pkritonitis. 
 
 1. The inflammation is mainly in the peritoneum, and 
 often not definitely localised in one part of the pelvis. 
 
 2. Pain very severe. Marked abdominal tension and 
 tenderness. Coils of intestines may be seen through the 
 wall. 
 
 3. A swelling may not be noticed for some days. It is 
 around the uterus generally, and does not bulge down 
 lateral fornices. The uterus is usually never displaced to 
 one side. 
 
 4. Naasea ; often bad vomiting. 
 
 5. Tympanites in severe cases. 
 
 6. Both legs often drawn up. 
 
 Pelvic Cellulitis. 
 
 1. The cellular tissue is mainly affected, usually in dis- 
 tinctly localised areas. 
 
 2. Pain not so severe. It often shoots down one leg. 
 There may be very little tenderness or rigidity in the 
 abdomen. 
 
 3. The swelling is easily felt on bimanual examination 
 as a localised mass. Very often the uterus is considerably 
 displaced. 
 
 4. Vomiting is not often marked. 
 
 5. No tendency to tympanites. 
 
 6. Marked tendency to formation of pus, which burrows 
 in definite directions. 
 
 
 '■I'k 
 
 % 
 
 
 K- 
 
 VV' 
 
 Iv' 
 
 :?' 
 
 
 
 •im 
 
V, 
 
 326 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 Treatment. — Practically the same as in the case of 
 pelvic peritonitis. It is important to precede measures by 
 curetting, if the endometrium be diseased, as it is so often 
 a source of infection. 
 
 When the bladder or rectum is diseased it should be 
 treated early. 
 
 When pus collections form, they should be opened. The 
 chief sites of these have already been mentioned. 
 
 Whenever, in such cases, it is possible to open into 
 these cavities without injuring the ureter, large vessels, 
 viscera, or the peritoneal cavity, the pus should be removed, 
 the opening being made through the skin or vaginal 
 surface. 
 
 Sometimes it is sufficient to aspirate the collection 
 when it is small. A large collection should be opened 
 freely. 
 
 Whenever there are important structures which might be 
 injured by a knife, a director should be pushed into the 
 abscess after an opening is made through the skin or 
 vaginal mucosa. The opening is then enlarged with dress- 
 ing forceps. In other CL^es the abscess may be freely 
 opened with a knife. If a finger can be introduced, any 
 septa or masses preventing free escape of the pus may be 
 broken down. 
 
 Drainage should be continued by means of iodoform 
 gauze, or by a rubber tube, after the cavity has been 
 washed out with an antiseptic lotion. The cavity should 
 be washed out once or twice each day. When the open- 
 ing is made high up in the vagina, it is a good plan 
 to stitch the tube to the edges of the opening for a 
 time. 
 
 When it is impossible to open a collection of pus seated 
 close to the rectum by means of the vaginal incision, it 
 should be opened by way of the gut without hesitation, the 
 rectum being carefully cleaned out beforehand. A large 
 opening should be made, vessels being avoided. It should 
 
PELVIC CELLULITIS. 
 
 327 
 
 be washed out three or four times daily, and should be 
 made to close from the bottom. The opening should be 
 kept large by the finger, in order that it may be the last to 
 close. If the sphincters of the anus be paralysed for a few 
 days, the cavity drains best. 
 
 When a pus collection has discharged into the vagina, 
 and healing takes place slowly, the opening should be 
 enlarged, and drainage kept up. 
 
 If i abscess has opened into th ^ rectum, the opening 
 should be enlarged, and all pockets destroyed. 
 
 After opening has taken place into the bladder, an effort 
 should be made to open into the abscess cavity between the 
 bladder and cervix, and to establish drainage. 
 
 If this be not possible, it may be necessary to make a 
 vesico-vaginal fistula, and to dilate the opening by which 
 the pus has entered the bladder. 
 
 Some large collections of pus in the cellular tissue 
 cannot be opened without the performance of an abdominal 
 section. The peritoneal cavity is opened and the pus is 
 aspirated. The walls of the sac are then stitched to the 
 edges of the abdominal wound. The opening into the 
 sac is next enlarged, the cavity washed out with an 
 antiseptic, and then stuffed with iodoform gauze. In 
 two or three days it is removed, and a smaller quantity 
 introduced. 
 
 Sometimes on opening the peritoneum it is found that, 
 owing to the fixation of the pus collection, its deep- 
 seatedness in the pelvis, or its adhesion to intestines, it 
 is impossible to attach its covering to the edges of the 
 abdominal wound. In such a case a careful examination 
 per vaginam should be made, in order to determine the 
 possibility of draining the pus by a vaginal puncture. If 
 this can be done, a j-shaped drainage-tube should be 
 introduced into the abscess cavity by way of the vagina. 
 The abdominal wound is then closed. 
 
 When an opening by way of the vagina cannot be made. 
 
 
 PP! 
 
 ,''|!l 
 
 % \\ 
 
 \\\. 
 
328 
 
 AFFECTIONS OF PERITONEUM, ETC. 
 
 the abscess may be opened, carefully cleaned, and drained 
 through the abdominal wound, by Mikulicz's iodoform gauze 
 tampon {pide p. 269). 
 
 Parametritis Chronica Atrophicans 
 (I. Circumscripta; II. Diffusa). 
 
 Freund has given this name to a slow chronic process 
 affecting mainly the fascial and aponeurotic structures, pro- 
 ducing changes similar to those found in cirrhotic pro- 
 cesses in the liver, kidney, etc. 
 
 The circumscribed variety. — The dense bands may be 
 found in relation to bladder, uterus, or rectum. The dis- 
 ease is believed to start in infection from these different 
 structures. As shrinkage occurs, more or less displacement 
 of one or other of them is produced. 
 
 The diffuse variety. — This is a rare condition in which a 
 cirrhotic process affects the whole pelvic cellular tissue. As 
 it progresses vessels are compressed, and there is con- 
 gestion and catarrh of urethra, bladder, uterus, and rectum. 
 The genitals gradually atrophy ; menstruation is at first 
 abundant, and afterwards scanty. The cause is not well 
 known. It has been attributed to a weakened condition, 
 produced by excessive child-bearing or suckling. 
 
 Symptoms. — These have been described in connection 
 with chronic inflammatory conditions in the pelvis. 
 Neurotic phenomena are usual-y marked. Menstruation 
 may be excessive at first, and afterwards scanty. 
 
 k 
 
 f 
 

 I 
 
 k 
 
 CHAPTER XI. 
 PELVIC h^:matocele and h^.matoma. 
 
 Nature. — These conditions are not diseases pe/- se, but 
 are outpourings of blood, resulting from various patho- 
 logical states. Haematocele is an infusion of blood into 
 the peritoneal cavity; haematoma, into the extraperitoneal 
 tissues. These conditions are most frequent in parous 
 women, in the most vigorous reproductive period, i.e. 
 between 25 and 35. 
 
 Etiology. — Rupture of bloodvessels may occur in abnormal 
 conditions of the tissues, and of increased blood pressure. 
 
 Thus, occasionally an effusion of blood may be brought 
 about during menstruation, usually from a sudden strain, 
 violent exercise, or violent coitus. Sudden chill of the 
 body during a period is said to induce it. 
 
 It may take place from a congested ovary, in connection 
 with the rupture of a Graafian follicle. Rupture c^f an 
 ectopic gestation sac is the most important cause. It may 
 occur from rupture of varicose veins under the peritoneum 
 in different parts of the pelvis. It may be found in con- 
 nection with the acute exanthemata, purpura, scorbutus, 
 haemophilia, and certain other rare conditions. 
 
 HvEMATOCELE. 
 
 Etiology. — Of all the causes of haematocele mentioned 
 above, there can be little doubt that by far the most 
 important is ectopic pregnancy. Lawson Tait has been 
 foremost in urging this view, and he states that the g*"':at 
 
 / 
 
330 PELVIC HALMATOCELE AND HEMATOMA. 
 
 majority of cases can be attributed to this condition. The 
 following statistics of other observers do not quite bear 
 out this statement : — 
 
 Thus in 66 cases observed by Veit, 
 ,, 20 ,, Jousset, 
 
 16 only were due to ruptured 
 9 ,, ectopic gestation. 
 
 5> 
 
 „ 17 „ Dubousquet, 5 „ „ 
 
 „ 36 ,, Voison, 9 ,, ,, 
 
 M 7 ., Engelhardt, i ,, »♦ ■ 
 
 Thus in 146 cases there were only — 40, or 28 per cent. 
 
 These statistics are not at all conclusive. The proportion 
 is far too small. In many case-j of haematocele, occurring in 
 the early weeks of an ectopic pregnancy, the real cause is 
 never suspected or recognised. Moreover, with the most 
 careful physical examination, it may be impossible to 
 determine it. Cullingworth has recently reported an in- 
 teresting series of twenty cases, in which he performed 
 abdominal section for haematocele. In every one the con- 
 dition was associated with tubal pregnancy. Escape of 
 blood into the peritoneal cavity in ectopic pregnancy may 
 take place in various ways. I have pointed out in my 
 former work, ' Ectopic Pregnancy," the conditions which 
 favour the occurrence of this complication. When gestation 
 takes place in a Fallopian tube, after a very early period the 
 musculature of its wall is not able to respond to the rapidly 
 developing ovum as does the normal fruit-holder, the 
 uterus. The normal relations of the muscle become greatly 
 altered, the bundles getting broken and separated, so that 
 as pregnancy advances many portions of the wall are 
 found without any muscle whatever, owing to the marked 
 scattering of fibres which has taken place, and to the 
 accompanying atrophy of the fibres which usually occurs. 
 The main structure in the wall is connective tissue. In this 
 condition of the gestation sac it is as easy to understand 
 how the wall may become stretched, thinned, and ruptured 
 by the pressure of the increasing contents, especially if 
 this be suddenly increased by intratubal haemorrhage, or by 
 
 !\ 
 
ETIOLOGY. 
 
 33 » 
 
 alterations in intra-abdominal pressure, e.g. sudden strains, 
 falls, etc. 
 
 The rupture in the wall may be large or small, the rent in 
 the tube being rounded, elongated, or irregular. In some 
 cases that part of the wall to which the placenta is attached 
 may burst, in others the non-placental portion ; in the 
 former the bleeding is most severe and the condition most 
 serious. The whole ovum, or only part of it, may escape 
 into the peritoneum ; according to Orthmann, in the majority 
 of instances complete expulsion takes place. The hole in 
 the tube may become plugged by the foetus sticking in it. 
 It is thus easy to understand how oO many variations are 
 found in the nature and extent of the rupture, the amount 
 of blood lost, and the danger to the mother. In a large 
 number of cases the condition will be fatal within twenty- 
 four hours, as a result of the pouring out of blood, unless 
 an operation be performed. Thus, Parry found that, out of 
 113 cases, thirty-nine died within ten hours, eighty-one within 
 twenty-four hours, and ninety-eight within forty-eight hours. 
 
 In many cases only a small loss of blood takes place, 
 and this may be followed at successive intervals by more 
 haemorrhage. The temporary cessations may be due to 
 contractions of the tube or vessel wall, or to plugging of the 
 rent by the foetal structures. A succession of small losses 
 may prove fatal to the mother after a short time. In some 
 cases blood may accumulate first in the tube, e.g. between 
 the wall and the placenta, and afterwards burst into the 
 peritoneal cavity. In another class of cases, where the tube 
 is surrounded with adhesions, the blood may only slowly 
 work its way through them. The earlier in pregnancy the 
 rupture occurs the less will be the immediate danger to the 
 mother, because the vessels are not much enlarged, and the 
 musculature of the tube wall not too much altered to con- 
 tract on the torn vessels and check haemorrhage. Also an 
 escaped ovum along with the blood will probably more 
 easily be absorbed in the early than in the late months. 
 
 ! r 
 
 pi 
 
 ('- 
 
332 PELVIC H/EMATOCELE AND H^KMATOMA. 
 
 The mother, therefore, during the first and second months, 
 runs somewhat less risk from rupture than during the 
 succeeding months. In the majority of cases of tubal 
 pregnancy rupture occurs during the first four months, 
 but it may also take place during the succeeding months. 
 During the first month it is rare, but has been reported 
 as taking place in the second and third weeks. A large 
 number of cases rupture during the second month. 
 In ninety-five cases reported by Hennig : — 
 
 Rupt 
 
 ur 
 
 e during the 1st month occurred in 5 
 
 
 
 2nd 
 
 >» 22 
 
 
 
 3rd 
 
 18 
 
 
 
 4th 
 
 23 
 
 
 
 Sth 
 
 n 8 
 
 
 
 6th 
 
 >i ^ 
 
 
 
 7th 
 
 „ I 
 
 
 
 Sth 
 
 ,. 6 
 
 
 
 9th 
 
 »» I 
 
 
 
 loth 
 
 9 
 
 Beyoi 
 
 nd the 
 
 loth 
 
 ,, I 
 
 cases. 
 
 In Von Schrenk's collected cases rupture occurred — 
 
 In the 1st month in 13 cases. 
 2nd ,, 67 ,, 
 3rd ,, 28 „ 
 4th „ 12 „ 
 
 
 In Schauta's cases. 
 
 In the 1st month in 15 cases. 
 „ 2nd ,, 29 „ 
 
 M 3rd 
 
 23 M 
 
 M 4th 
 
 10 „ 
 
 In Mackenrodt's cases 
 
 : — 
 
 In the 1st month 
 
 in 6 cases. 
 
 „ 2nd „ 
 
 23 ,. 
 
 ,. 3rd 
 
 5 „ 
 
 M 4th 
 
 4 ,: 
 
 Another important factor is the patency of the fimbriated 
 end of the tube in the early weeks of pregnancy. This is 
 
 !\ 
 
ETIOLOGY, 
 
 333 
 
 found in varying degrees. In a certain number of cases it 
 is completely closed at an early period by perisalpingitis, or 
 by adhesions to neighbouring structures. This may not, 
 however, take place until pregnancy has considerably ad- 
 vanced. Closure may be quickly brought about, or only 
 gradually, so that many variations are found in the degree 
 of patency which exists in different cases. Through this 
 open end blood may escape in small or large quantities, 
 if rupture of a vessel occur, causing haemorrhage within the 
 tube. Probably the most frequent source of the blood in 
 such cases is the decidua reflexa, though it may also come 
 from the serotina and vera. In my researches in ectopic 
 pregnancy I have pointed out the very delicate nature of the 
 reflexa, its great vascularity, the rapid degenerative processes 
 in it, and the tendency to haemorrhage in it. Blood is often 
 found escaping from the maternal sinuses of the reflexa into 
 the surrounding decidual tissue ; and it may burst through 
 the reflexa, either on its inner side, coming into relation with 
 foetal structures, or on its outer side, forming a blood mass 
 in the tube outside the ovum. On its inner surface a 
 greater or less area forms, along with the serotina, the side 
 for the attachment of the permanent placenta, the rest of 
 it being related to the temporary chorion Iceve. These 
 relationships afford an explanation for the almost constant 
 occurrence of blood effusions in the placenta or membranes 
 of a tubal pregnancy. 
 
 It is highly probable that this origin of haematocele is 
 much more frequent than has been thought. It is, indeed, 
 remarkable that in Cullingworth's twenty cases the blood was 
 found escaping from the open end of the unruptured tube. 
 In the majority of instances, the escape had taken place 
 very slowly, the blood trickling out gradually, thus allowing 
 progressive clotting and encapsulation to take place ; very 
 rarely does the blood escape so rapidly from the open end 
 as to lead to a diffusion of free blood throughout the general 
 peritorical cavity. This author believes, and I agree with 
 
 m 
 
 ■A 1 1 ' 
 
 I in 
 
 \ ) 
 
 \A 
 
334 PELVIC H^IMATOCELE AND HAiMATOMA. 
 
 him, that the majority of the favourable cases of haematocele 
 are those in which the escape of blood has taken place by 
 the open end of the tube in very early tubal pregnancy. 
 
 The blood which escapes through the fimbriated extremity 
 may be accompanied with part or whole of the gestation 
 products — the so-called " tubal abortion." The abortion is 
 most apt to occur before the ostium abdominale is closed, 
 i.e. during the first two months, in most cases, but it may 
 take place if the ostium be closed with recently formed 
 weak adhesions. 
 
 In thirty-two cases collected by Mackenrodt — 
 
 It occurred during the 1st month in 8 cases. 
 „ 2nd ,, 19 ,, 
 
 3«1 ,, 4 ,, 
 
 4lh .. I „ 
 
 »» 
 
 >> 
 
 In twenty-nine cases occurring in A. Martin's hospital, 
 reported by Orthmann — 
 
 ■ It occurred during the 1st month in 13 cases. 
 
 2nd ,, 10 ,, 
 
 3>"d „ 4 „ 
 
 4th ,, 2 „ 
 
 
 The expulsion probably takes place as a result of the 
 contractions of the muscular part of the tube wall, the tubal 
 contents. moving in the direction of least resistance. It can 
 most easily take place when the ovum is primarily situated 
 in the outer part of the tube ; but it is to be remembered 
 that the ovum may be moved some distance along the tube. 
 In most cases, according to Orthmann, the ovum is com- 
 pletely expelled. 
 
 The results of tubal abortion, as far as the woman is 
 concerned, are very variable. A large quantity of blood 
 may be poured out quickly in the peritoneal cavity, 
 endangering her life, and death may be immediate or 
 delayed. A large localised haematocele may be formed, or 
 a small one in some cases. As regards the ovum, various 
 
 
 \\ 
 
ETIOLOGY. 
 
 335 
 
 changes may take place ; if pregnancy be early, it may be 
 easily absorbed when it escapes into the peritoneal cavity. In 
 many of these cases extravasations may be found in the foetal 
 envelopes ; these haemorrhages leading to the death of the 
 ovum, and forming the so-called " mole," lead to the abortion. 
 
 In nineteen cases in which Cullingworth found tubal 
 mole, with haemorrhage from the free end of the tube, 
 pelvic haematocele resulted in seventeen cases, and a free 
 effusion in the peritoneal cavity. 
 
 In nine cases in which rupture of the tube occurred, free 
 intrapelvic effusion occurred in seven cases, pelvic haemato- 
 cele in one, and haematoma of the broad ligament in one. 
 
 After the early months, when the placenta is a well- 
 formed structure, partial or total escape of it into the 
 peritoneal cavity, with or without the foetus, is probably 
 always fatal to the woman unless operation be carried out. 
 When the foetus alone passes into the peritoneal cavity, its 
 fate varies. If it be young, it may be gradually disintegrated 
 and absorbed by the peritoneum. Older foetuses may be 
 partly absorbed, or may, with or without partial absorption, 
 become encapsuled by peritonitis ; this may be followed by 
 death or suppuration, or the foetus may become shrivelled, 
 and be turned into adipocere or a lithopaedion. 
 
 In some cases, as Orthmann has pointed out, the ovum 
 may escape without any blood, though blood-clot may be 
 found in the tube. He also states that such a combination 
 is never found when the ovum escapes through a rupture of 
 the tube wall ; in such a case, blood is always found in the 
 peritoneal cavity. 
 
 While Orthmann's observations are quite correct, it is 
 probable that, in the majority of cases in which abortion 
 occurs by way of the outer end of the tube, a little blood 
 may escape along with the ovum ; but that it is so small in 
 amount as to be rapidly absorbed by the peritoneum. 
 
 In some cases _ haematosalpinx may be formed along 
 with the haematocele ; and, according to Werth, the outer 
 
 I,' 
 'It 
 
 { :]i 
 
 i;^ 
 
 .' !■ 
 
 lii 
 
 ri; 
 
 
 \\ 
 
336 PELVIC H/EMATOCELE AND HEMATOMA. 
 
 ; : 
 
 end of the tube may become closed after the escape of 
 blood, so that the haematocele and hnematosalpinx become 
 distinct from one another. 
 
 A view long held as to the origin of many cases of 
 hiTematocele is that of Bernutz, who regarded them as due 
 to a reflux of menstrual blood from the uterus. 
 
 Many now believe, among whom Bland Sutton is fore- 
 most, that the cases of this supposed origin are mainly 
 those in which tubal abortion has occurred. 
 
 The supposed menstruation is the bleeding which may 
 take place from the altered mucosa of the uterus in ectopic 
 pregnancy. As there is only a slight escape from the 
 uterus in such cases, it is easily understood how the belief 
 has been readily accepted that the blood has regurgitated 
 through the Fallopian tubes. 
 
 In cases where the htematocele forms without any external 
 bleeding, the opinion has been often expressed that the 
 haematocele is due to a reflux of blood from the tube apart 
 from the influence of an ectopic gestation. 
 
 All such opinions must be taken with caution. Cases 
 must be examined with great care to ascertain the existence 
 of ectopic gestation, and at the time of operation or post- 
 mortem to make out the real source of the haemorrhage ; 
 above all, a microscopic examination of the tube and clots 
 should be made to decide as to the presence or absence of 
 foetal structures. 
 
 A rare cause of hoematocele is the rupture of a tumour, 
 e.g. an ovarian cyst in which haemorrhage has taken 
 place. 
 
 Gardner has described t\70 interesting cases, in one of 
 which the haematocele was associated with adeno-carcinoma 
 of the ovary, and in the other, with tuberculosis of a Fall- 
 opian tube, which had become distended with blood and 
 had ruptured. 
 
 Pathology. — Sometimes the patient may die from the 
 amount of blood poured out. Then only fluid blood is 
 
 / » 
 
 ! \ 
 
PATHOLOGY, 
 
 337 
 
 Fig. 86. — Haematocele in which the 
 uterus lies anterior, close to the 
 abdominal wall. 
 
 found in the peritoneal cavity. In less severe cases the 
 
 following conditions are found : — 
 
 The blood extends from the pelvis upwards for varying 
 
 distances. It may surround the uterus, push it forwards, 
 
 backwards, or to one 
 
 side. It becomes gradu- 
 
 ally clotted, forming a 
 
 dark-red mass. Fibrin 
 
 gradually spreads through- 
 out it, and it becomes 
 
 more organised, solid, 
 
 and paler in colour. 
 
 (Many of the red blood 
 
 corpuscles are probably 
 
 absorbed through the 
 
 peritoneum early after 
 
 rupture.) An inflammatory reaction usually occurs around 
 
 the mass, and there is some serous effusion into the peritoneal 
 
 cavity. The bowels get matted together to form a roof over 
 
 the blood mass. Sometimes only the outer portion of the 
 
 blood is solid, the central 
 part consisting of one or 
 more cavities containing 
 altered blood, of a dark, 
 tarry nature. Or solidifi- 
 cation may occur irregu- 
 larly. 
 
 Course. — Many cases 
 gradually become cured by 
 gradual absorption. Some- 
 times considerable thick- 
 enings may remain for a 
 
 long time. In some cases suppuration occurs, and a pelvic 
 
 abscess is formed which may tend to burst in a variety of ways. 
 Sometimes the mass increases at menstrual periods, owing 
 
 to increased haemorrhage or inflammation. 
 
 22 
 
 Fig. 87. — Haematocele under which the 
 uterus lies retroverted. 
 
 ! i': 
 
 \i. 
 
 .4ii 
 
V. 
 
 338 PELVIC H/EMATOCELE AND H/EMATOMA. 
 
 Symptoms. — These vary according to the rapidity with 
 which the blood is poured out, and to the quantity. 
 
 In a well-marked case, there is sudden pain, accompanied, 
 often, with a feeling of fear ; pallor, prostration, collapse ; 
 perspiration, nausea, vomiting. The pulse may become 
 feeble. There is menorrhagia in some cases ; sometimes the 
 menstrual flow ceases, generally reappearing after a few days. 
 In some cases anaemia and amenorrhoea may last for 
 a considerable time. 
 
 The pains are often rhythmical ; sometimes colicky. 
 There may be a feeling of weight in the pelvis ; also 
 
 rectal and vesical tenesmus ; 
 sometimes retention of urine. 
 There is apt to be a re- 
 crudescence of pain at suc- 
 ceeding menstrual periods. 
 
 When inflammatory reac- 
 tion occurs the temperature 
 and pulse rise. 
 
 As the mass gradually 
 shrinks and absorbs, the 
 Fig. 88.-Hoematocele in which patient is more or less com- 
 
 the uterus is embedded in the _ , , , , _ 
 
 centre of the muss. fortable, though often some 
 
 degree of pelvic discomfort 
 or pain is experienced. There is generally a tendency to con- 
 stipation ; sometimes diarrhoea and passage of bloody mucus. 
 
 When suppuration occurs, the symptoms of abscess are 
 marked. 
 
 Physical signs. — When abundant blood is poured out, 
 signs of free fluid in the peritoneum are present. Per 
 •vaginam a boggy feeling is got through the fornix. As 
 coagulation occurs the mass may be made out. At first it 
 is difficult to feel this through the abdomen, owing to the 
 tenseness and tenderness of its wall. Afterwards it may be 
 made out bimanually as a firm elastic mass, filling the pelvis 
 and reaching up, it may be, above the umbilicus. The 
 
DIFFERENTIAL DIAGNOSIS. 
 
 339 
 
 lower surface of the mass is somewhat concave. The 
 uterus may be felt in front of the mass against the sym- 
 physis ; behind, laterally displaced ; or it may not be 
 found at all, being in the midst of the blood. On per- 
 cussion over the abdomen there is dulness over the palpable 
 portion. It may be more on the right side in some cases, 
 and in others more on the left. As the tumour gets 
 older it becomes harder, and furrows often develop on it. 
 Its consistence may be felt to be different at different 
 parts. 
 
 In some cases there may be slight distension of the 
 intestines above the mass. 
 
 Differential diagnosis. — i. Ectopic pregnancy. 
 
 2. Pelvic peritonitis or cellulitis with effusion. 
 
 3. Myoma uteri ; myoma with peritonitis or cellulitis ; 
 myoma with torsion of pedicle. 
 
 4. Ovarian tumour ; tumour with peritonitis ; tumour 
 with twisted pedicle. 
 
 5. Posterior displacement of gravid or non-gravid uterus. 
 
 6. Haematosalpinx. 
 
 7. Retained menstrual blood in atresia of vagina or 
 cervix, or in the horn of a malformed uterus. 
 
 Treatment. — The patient must be put to rest in bed. 
 At first ice-bags should be placed on the abdomen, 
 and ergotine given hypodermically. If there be collapse, 
 brandy, ether, or strychnine should be administered ; and, 
 if necessary, saline solution should be injected subcutane- 
 ously or into the veins. The diet should be low and simple, 
 e.g. milk, beef-jelly. 
 
 Sometimes morphia may be necessary on account of the 
 pain. 
 
 As the case goes on the cold applications are to be con- 
 tinued, and the ergot may be given by the mouth. The 
 bowels should be kept regular. More nourishing diet and 
 tonics are to be administered. 
 
 Local inunction of the abdomen and vagina with iodine, 
 
 , % 
 
 % 
 
 i 
 
 
 ■:.'(\ 
 
 . : V<\ 
 
 IH 
 
 '^IH 
 
V, 
 
 340 PELVIC H/EMATOCELE AND H/EAfATOMA. 
 
 iodide of potassium, etc., has been employed, but with no 
 very distinct benefit. 
 
 Surgical measures. — The exact position of surgical pro- 
 cedure in recent cases of haimatocele has not been definitely 
 fixed. The reason of this is our uncertainty in regard to 
 all the causes which may give rise to the condition. 
 Within recent years recognition of the importance of 
 rupture of an ectopic pregnancy as a cause has led to 
 early active interference. It is extremely likely that, in 
 the future, similar measures will be adopted in all cases of 
 intraperitoneal haimorrhage, whether the cause be known 
 to be ruptured ectopic gestation or not, unless it be of 
 such a nature as to preclude the possibility of remedial 
 surgical interference, e.}:;;. rupture of a large aneurism. 
 
 Cullingworth thinks it may be safe to withhold operative 
 measures when the ectopic pregnancy is in the very early 
 weeks. 
 
 The course to be taken is the following : — The peritoneal 
 cavity is opened, and the bleeding point found and con- 
 trolled. If the case be one of ectopic gestation, the 
 procedure varies, according to the condition found 
 on examination. If the patient be much collapsed, it is 
 well to transfuse blood, or to give an intravenous or sub- 
 cutaneous injection of saline solution, in order to improve 
 her for the operation. Hypodermic stimulant injections 
 may also be needed. 
 
 After opening the abdomen, the first step is to find the 
 rupture and to check bleeding from it with forceps or 
 ligatures. If the tear be large or irregular, it may be 
 impossible to do this quickly ; or in carrying out the pro- 
 cedure the tear may be made worse, owing to the thinness 
 of the sac. In these circumstances the infundibulo-pelvic 
 ligament should be clamped with a pair of forceps, so as to 
 secure the ovarian artery, and no time should be lost in 
 ligaturing the broad ligament and removing tube and ovary. 
 
 I;i cases in which abdominal section is carried out some 
 
TREATMENT. 
 
 341 
 
 time after the first escape of blood, the operation may be 
 considerably complicated by adhesions due to peritonitis. 
 
 If the case be one in which the ha^matocele is due to the 
 secondary rupture of a broad ligament, into which a tubal 
 pregnancy has, first of all, burst, the whole gestation sac 
 should, if possible, be removed. If this cannot be done, 
 the ovarian artery should be ligatured, and the rent in the 
 sac, if near the abdominal wall, stitched to the edges of the 
 incision in the latter. If the rent be distant from the 
 abdominal wall, it should be closed with catgut. Then the 
 sac should be stitched to the edge of the abdominal in- 
 cision, and a new opening made in it through which 
 iodoform can be introduced ; the sac thereafter gradually 
 contracts and closes. Should there be a rupture of 
 the broad ligament, the bleeding vessels must be 
 thoroughly secured with strong catgut ligatures. If the 
 abdominal vircera be ruptured, the treatment should be 
 carried out as recommended in surgical treatises. In all 
 cases the blood is to be thoroughly removed from the peri- 
 toneal cavity, which should be irrigated with salt solution, 
 some of which may be left to be absorbed by the peri- 
 toneum, to make up for the loss of blood. In some cases 
 drainage may be carried out, especially where matter other 
 than blood has entered the peritoneal cavity, where there is 
 difficulty in removing all the blood, or where there is some 
 fear that the fluid is not perfectly aseptic. 
 
 Hsematocele of some duration in which suppuration has 
 occurred. — The treatment is to open into the mass, remove 
 the pus, break down the clot, wash out the cavity with an 
 antiseptic, and drain it freely. The place of opening in 
 such a case must depend on circumstances. The operator 
 must be guided by tl" 'position and extent of the pus, by 
 the direction in which . tending to point, by the relation- 
 ship of the intestine s, and by the necessity of selecting the 
 best tract for drainage. 
 
 There can be no doubt that the vaginal opening is the 
 
 
 
 \m 
 
V, 
 
 342 PELVIC HEMATOCELE AND HEMATOMA. 
 
 l>« 
 
 best when most of the blood mass is broken down and can 
 be removed ; when the mass is of small size it affords the 
 best means of drainage. Some, however, prefer in these 
 cases to make the opening in the abdominal wall. It is 
 probably best to remove the fluid by an abdominal opening 
 and to drain afterwards by a vaginal opening, the former 
 being closed. 
 
 When the blood mass is large and not much broken 
 down the incision should be in the abdominal wall, if 
 possible directly over the pus collection. As much of the 
 mass as will easily come away should be removed and the 
 cavity packed with iodoform gauze. In all these cases care 
 must be taken not to injure the intestines. They are 
 generally matted together to form the upper boundary of 
 the haematocele, which is thus shut off from the rest of the 
 peritoneal cavity. 
 
 Ha: M ATOM A. 
 
 Hiemorrhage into the extraperitoneal cellular tissues of the 
 pelvis is due to the same causes which produce haematocele. 
 The blood goes through the same changes as those already 
 described. 
 
 Symptoms. — These are somewhat similar to those in 
 haematocele, only much less severe. There is rarely any rise 
 of the temperature following the haemorrhage. 
 
 Physical signs. — When the effusion has taken place in a 
 broad ligament, the uterus is pushed towara^ the opposite 
 side of the pelvis, and the fornix on the corresponding side 
 is p'lshed downwards. 
 
 Through the abdominal wall the upper surface may be 
 very clearly defined, and, sometimes, the appendages can 
 be distinguished. 
 
 Sometimes the blood extends all round the uterus, and 
 then there is a bulging down of the whole vaginal fornix. 
 In some cases the peri-rectal tissue may be the seat of 
 
HEMATOMA TREATMENT. 
 
 343 
 
 the haemorrhage, and a mass may be found which is lateral 
 to the gut or which presses forward in front of it, displacing 
 the uterus. Sometimes a haematoma ruptures into the 
 peritoneal cavity. 
 
 Treatment. — The general treatment is the same as 
 for haematocele. 
 
 As regards surgical measures, no interference is necessary 
 save under certain conditions, when the hsematoma is due 
 to the rupture of a tubal pregnancy into the broad ligament, 
 the foetus not being destroyed. 
 
 When a hsematoma ruptures into the peritoneal cavity, 
 giving rise to a haematocele, 
 it is probably best to open 
 into the peritoneal cavity, 
 from which all blood is washed 
 out, to stitch the edges of the 
 ruptured sac to the abdom- ■^< 
 inal wound, or, if this be 
 not possible, to close the rent 
 with continuous catgut. The 
 ovarian artery should then be 
 ligatured in the outer part of 
 the broad ligament on the 
 bleeding side, and, if possible, 
 the uterine artery also. The 
 top of the blood sac should 
 
 then be carefully sutured to the abdominal wound. The 
 sac should be opened, the blood clot removed, and anti- 
 septic gauze packed in its place. This should be changed 
 and lessened in amount every few days. 
 
 When suppuration occurs in a haematoma the condition is 
 treated as a pelvic abscess. 
 
 Fig. 89. — Hoematoma of the right 
 broad ligament. The transverse 
 section of the pelvis shows how 
 tlie uterus is displaced by the 
 blood. 
 
 ■ 
 
 
 Mi 
 
 M 
 
 i 
 
 1 -rl 
 
344 PELVIC HEMATOCELE AND HEMATOMA. 
 
 Other Affections of the Pelvic Connective 
 
 Tissues. 
 
 Cysts of the broad ligament. — Besides blood and inflam- 
 matory cfifusions, parovarian, hydatid, and other cystic 
 conditions are found in the broad ligament. These will 
 be considered along with cysts of thj ovary. 
 
 Solid tumours of the broad ligament. — These are 
 fibroma, fibromyoma, lipoma, phleboliths, carcinoma, sar- 
 coma, tubercle. 
 
 The latter three conditions are practically beyond surgical 
 treatment. The other forms are only to be removed when 
 they are growing rapidly, when they are causing pressure 
 symptoms, or when they are apt to be a cause of obstruction 
 in future labours. 
 
 The most satisfactory method of operation is by abdom- 
 inal section. The peritoneum is opened, in most cases 
 the lateral incision being used. The ovarian artery in 
 the outer part of the broad ligament is tied. An incision 
 is made through the anterior peritoneal covering of the 
 tumour, i.e. the layer of the broad ligament. The tumour 
 is shelled out by means of the hand, and removed. If there 
 is much bleeding from the interior of the sac, the uterine 
 artery on the same side is ligatured. 
 
 The sac may be treated in either of two ways, of which I 
 recommend the first. 
 
 The two layers are brought together from below upwards 
 by means of a continuous catgut suture. When this is 
 done, the broad ligament appears on the side occupied by 
 the tumour, as a thickened crumpled mass at the side of 
 the uterus. Or the edges of the sac may be stitched to 
 the abdominal wound, packed with antiseptic gauze, and 
 thus drained. 
 
 Solid tumours of the round ligament.— Fibroma, fibro- 
 myoma, fibromyxoma, and sarcoma may occur within 
 

 1 
 
 
 OTHER AFFECTIONS OF THE PEL VIC TISSUES. 345 
 
 the peritoneal cavity, in the inguinal canal, in the labia 
 majora. 
 
 The latter are the most common. The extraperitoneal 
 forms may be removed by external incisions in the groin, 
 unless too great extension into the neighbouring pelvic 
 connective tissue has taken place. The intraperitoneal 
 forms may be removed, unless they have spread too far, by 
 means of an abdominal incision. 
 
 Retroperitoneal tumours in the pelvis or lumbar 
 regions. — These may sometimes be removed by abdominal 
 section if they are not too large or malignant. The peri- 
 toneal covering should be incised and the tumour shelled 
 out, care being taken to avoid injuring important nerves, 
 vessels, or the ureter. Bleeding points should be tied, the 
 peritoneal flaps, which covered the tumour, being brought 
 together, save at the lowest point. Drainage of the peri- 
 toneal cavity should be kept up for a day or two. 
 
 Tumours in the pelvic connective tissue, elsewhere than 
 in the broad and round ligaments. — Dermoid cysts, 
 fibroma, fibromyoma, and sarcoma may be found, e.g. in 
 the recto-vaginal septum, at the side of the rectum, etc. 
 
 In some cases these can be removed by incisions made 
 externally. 
 
 Hydrocele of the round ligament. — This is a collection 
 of fluid in the canal of Nuck — a tube of peritoneum 
 extending into the labium majus. It may communicate 
 with the peritoneal cavity or be shut off at the internal 
 inguinal ring. It must be diagnosed from ovary prolapsed 
 into the inguinal canal and from inguinal hernia. 
 
 When it exists as an encysted hydrocele there is an oval 
 translucent swelling in the inguinal canal. It cannot be 
 pressed into the abdomen, is not tender, and causes no 
 symptoms. 
 
 When in the labium majus, the latter is distended with 
 a fluctuating translucent tumour, which cannot be returned 
 into the abdomen. 
 
 
 'i \ 
 
 '\m 
 
346 PELVIC HEMATOCELE AND HEMATOMA. 
 
 Treatment, — The most satisfactory treatment is to cut 
 down upon the cyst and dissect it out, closing the wound 
 with continuous catgut suture. 
 
 If the cyst communicate by an unobliterated passage with 
 the peritoneum by means of the inguinal canal, it is well, 
 after dissecting out the sac, to place a ligature immediately 
 above it in order to close the passage in the inguinal canal. 
 The wound is then to be closed with continuous catgut. 
 
 1 1 
 
 
CHAPTER Xn. 
 
 AFFECTIONS OF THE FALLOPIAN TUBES. 
 
 Anomalies of structure. — Sometimes the tubes are abnor- 
 mally long or abnormally short ; sometimes of unequal length. 
 The outer end varies greatly in shape, in size, in the number 
 and development of the fimbriae. Sometimes the fimbriae 
 are wanting. In some cases there are accessory fimbriae ; 
 these may be without or with an accessory ostium, which 
 communicates with the lumen of the tube. Occasional-y 
 two accessory ostia are found. 
 
 Anomalies of position. — Various displacements are 
 found, either of congenital origin, or due to acquired 
 causes. The latter are associated with inflammatory 
 changes, malpositions of ovaries and uterus, tumours and 
 swellings of various kinds. 
 
 Stricture and occlusion. — These may be congenital. Most 
 commonly they are due to a tumour in or outside the tube 
 or to inflammatory changes. The stricture may occur at 
 the outer, inner, or middle portion. They are important in 
 relation to the causation of sterility and to the accumulation 
 of fluid in the tubes. 
 
 U 
 
 
 Inflammation of the Tubes— Salpingitis. 
 
 Etiology. — I. Microbial infection from the genital tract, 
 especially following abortion and labour ; a most frequent 
 cause. 
 
 2. Infection associated with latent gonorrhoea in the 
 
^v. 
 
 348 AFFECTIONS OF THE FALLOPIAN TUBES, 
 
 male ; a common cause. In cases in which the gonococcus 
 is absent, the infection is due to septic cocci which have 
 
 developed in the 
 discharges. Acute 
 gonorrhoea may 
 also give rise to 
 salpingitis. 
 
 3. Spread of in- 
 flammation from 
 
 KiG. 90.— Fallopian tube, with accessory ostium, neighbouring parts. 
 
 4. Severe chills, excessive coitus, or excessive exercise 
 during or near menstruation are said to cause salpingitis 
 sometimes. 
 
 5. Acute exanthemata. 
 
 6. Tuberculosis \ actinomycosis. 
 
 Pathology. — The most important changes occur in the 
 mucosa, but all parts of the 
 wall are usually affected at ,|^^^ 
 the same time. 
 
 When the peritoneum 
 covering the tube is affected 
 it may be a localised inflam- 
 mation or part of a wider 
 affection. 
 
 It leads to bending, stric- 
 ture, displacement, or to Fig. 91.— Salpingitis. The mucous 
 
 adhesion of the tube to SUr- fringes have become fused together, 
 
 -, ^^ . so that the spaces between them 
 
 roimdmg parts. Very often j.^^^ ^^^^ ,^^,g,iy obliterated. 
 
 the mflammation spreads to Next the lumen of the tube the 
 
 the ovary. It may close the ^'"'"2 epithelium is mostly de- 
 outer end by matting the 
 
 fimbriae together. When the muscular portion of the wall 
 is affected, it becomes thicker and hard, owing to the small- 
 celled infiltration in it ; when pus is present, small loculi 
 may be formed throughout it. 
 
 When the mucosa is affected various changes are pro- 
 
HYDROSALPINX. 
 
 349 
 
 Fig. 92. — Pyosalpinx. The 
 nmcovis fringes are obliter- 
 ated, the lining epithelium 
 destroyed, and tl" mus- 
 cular part of the wall 
 greatly altered by chronic 
 inflammatory changes. 
 
 duced. Infiltration and effusion take place into the 
 delicate fimbriae and into the thin layer of submucous 
 tissue. There is congestion of the vessels. Small haemor- 
 rhages are sometimes found. There is increased mucous 
 secretion into the lumen, and 
 it may contain leucocytes, shed 
 epithelial cells intact or breaking 
 down, and, sometimes, red blood 
 corpuscles. The epithelial lining 
 is lost in some parts, degener- 
 ated in others, and adhesions may 
 occur between neighbouring plicae. 
 Sometimes the fringes may en- 
 large and vegetations may form 
 in connection with them. These 
 appear like polypi, on transverse 
 section. The inflammation may 
 go on to pus formation. 
 
 As a result of adhesions of the mucosa, occlusion of the 
 tube may be brought about in one or more places. If 
 fluid continues to be poured into the lumen, the tube gets 
 distended and the condition of hydro- or pyosalpinx is 
 produced. 
 
 In the cases in which a slow chronic interstitial change 
 
 is the main one 
 the tube may be- 
 come very hard 
 and somewhat 
 thickened. In ad- 
 vanced stages an 
 atrophy is some- 
 times produced as 
 absorption occurs. The lumen may be obliterated partly or 
 wholly by adhesion of the walls, and unobliterated portions 
 may give rise to small cysts. 
 
 Hydrosalpinx. — This is the distended condition of the 
 
 Fig. 93. — Contorted Fallopian tube, with marked 
 perisalpingitic thickening. 
 
 
 1! 
 
\v 
 
 350 AFFECTIONS OF '^HE FALLOPIAN TUBES. 
 
 tube, as a result of inflammatory serous fluid poured into 
 the lumen, the outer and inner ends having been closed. 
 In some cases it is the advanced stage of a pyosalpinx. 
 The tube becomes enlarged and elongated, tortuous, and 
 pear-shaped, with constrictions. It rarely gets larger than a 
 small pear, though it may be larger. The outer surface is 
 smooth, whitish blue in colour ; the walls are thin and 
 translucent. There are often thin adhesions present. The 
 fluid is citron-coloured ; sometimes it contains flakes of 
 lymph or a little blood. The cavity has usually one 
 
 compartment, but may have more 
 than one. The condition may 
 exist on both sides. In some 
 cases the uterine end of the tube 
 may not be completely closed, but 
 only stenosed, so that fluid may 
 escape into the uterus ; this con- 
 dition is termed "hydrops tubae 
 profluens." The mucosa becomes 
 very thin as the tube distends. The 
 fimbriae get gradually obliterated, 
 and may be found only as low 
 ridges. The muscular coat also 
 Sometimes the distended tube has a narrow 
 pedicle, owing to rotation. 
 
 Pyosalpinx — This is a distension of the tube as a result 
 of purulent salpingitis. The distension may be uniform, 
 but generally the wall is somewhat constricted in parts. It 
 may be produced quickly, as the result of an acute inflam- 
 mation or as a chronic condition. Sometimes a hydro- 
 salpinx may become purulent. The least alteration is found 
 near the uterus. In extreme cases the enlargement of the 
 tube may reach the size of a child's head. It may reach 
 into the abdomen. The wall is bluish white and varies in 
 thickness at different points. Adhesions are found attached 
 to various structures. The lumen may be single or partly 
 
 KiG. 94. — pyosalpinx. 
 
 atrophies. 
 
 (\ 
 
PYOSALPINX. 
 
 351 
 
 divided into compartments. The mucosal fringes are more 
 or less obliterated, and the surface has the ordinary appear- 
 ance of an abscess cavity. The pus is generally thick and 
 yellow. In old cases it may become a thin fluid with 
 masses of lymph and pus floating in it. It has a foetid 
 odour when the sac is adherent to the bowel. On micro- 
 scopic examination, the wall is found to be lined with 
 mucosa altered by inflammation. The lining epithelium 
 is mainly absent, but may be found somewhat altered, 
 especially in depressions in the mucosa. 
 
 The fimbriated end is rarely free. Generally the fimbriae 
 are matted together, or adherent to the ovary, or to some 
 part of the peritoneum. 
 
 When both tubes are affected, the left is usually larger 
 than the right. 
 
 The muscular part of the wall thins as distension occurs, 
 but thickenings may be brought about by inflammatory in- 
 filtration. A pyosalpinx may rupture into the peritoneal 
 cavity, setting up sevfere peritonitis. It may also open into 
 the rectum, especially when on the left side. Sometimes 
 it may open into the bladder or va'^ina, or through the 
 abdominal wall. It may also burst among surrounding 
 adhesions and be prevented from extending. 
 
 It has been noted that pyo- and hydrosalpinx occur in a 
 certain percentage of cases of carcinoma uteri. 
 
 Bacteriological examination of diseased tubes shows that 
 sometimes the gonococcus alone is present, but more 
 usually with streptococci or staphylococci. In other cases 
 the latter only are found. Rarely the pneumococcus or 
 Bacterium coli commune has been detected. In many cases 
 of distended tubes the fluid is sterile. 
 
 Sometimes the ovary is infected from the tube, and an 
 abscess formed in it which communicates with the pyo- 
 salpinx, forming the condition of tubo-ovarian abscess. The 
 communication may take place by the outer ostium of the 
 tube, or this may be closed and a new opening made. The 
 
 
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 352 AFFECTIONS OF THE FALLOPIAN TUBES. 
 
 tubo-ovarian abscess may burst into the peritoneum or may 
 open into the rectum. In the latter case it is usually the 
 ovary which makes the com.munication. 
 
 Ssrmptoms. — It is impossible to present a clear account of 
 the symptomatology of salpingitis, especially in relation to 
 the different varieties. In acute cases, and very often in 
 chronic cases, there are inflammatory changes in the neigh- 
 bouring ovary, uterus, peritoneum, or connective tissue, so 
 that there is difficulty in assigning to each part its proper 
 share of symptoms. Pain is felt in the side affected. At 
 first it may be intermittent, afterwards constant. It is 
 aggravated at menstruation, and often on cf itus ; there is 
 
 \^ 
 
 Fig. 95. — Tubo-ovarian abscess. 
 
 menorrhagia and often metrorrhagia; when the disease is 
 bad and bilateral, sterility; in pyosalpinx cases drops of 
 pus may find their way through the tube wall from time to 
 time, causing sharp attacks of pain and localised peritonitis. 
 Defaecation is often painful. 
 
 When large distensions of the tubes are formed, there are 
 often very few symptoms. There may be a period of im- 
 provement after a stage of activity. It is possible that this 
 may be due to the sterilisation of the tube contents, whereby" 
 the fluid loses its virulence. Symptoms may, however, be 
 caused by pressure of distended tubes against bowel or 
 bladder, especially when fixed with adhesions. 
 
 t \ 
 
PYOSALPJNX, 
 
 353 
 
 Some cases of hydrosalpinx may exist for years without 
 causing symptoms. 
 
 In the case of hydrops profluens there may be an occa- 
 sional discharge of fluid into the uterus and through the 
 vagina. 
 
 In many of these cases reflex pains are established, and 
 various neurotic phenomena may become marked. 
 
 When a distended tube ruptures into the peritoneal 
 cavity, severe acute general peritonitis may be set up. In 
 some cases this does not occur, owing to the sterile nature 
 of the contents. When rupture occurs into the rectum the 
 symptoms generally improve. 
 
 Physical signs. — Where there is considerable surrounding 
 peritonitis, and the tube is not much enlarged, it is usually 
 impossible to distinguish the tube from neighbouring 
 structures. 
 
 When the tube is thickened, it may be palpated on 
 bimanual examination, the patient complaining of pain. 
 When the ovary is affected, it may be difficult to distinguish 
 it from the tube, both being blended by adhesions. 
 
 When the tube is much distended, it may sometimes be 
 palpated through the lower abdominal wall. Generally it is 
 best made out on bimanual examination, at the side of the 
 uterus, behind it, or sometimes in front of it. There is 
 usually tenderness felt by the patient. The examination is 
 often best made by the abdomino-rectal method. The 
 most satisfactory exploration is obtained when anaesthesia is 
 employed. 
 
 Treatment. — In the early acute stages rest in bed is 
 necessary. The remedial methods to be employed are 
 much the same as described in connection with pelvic peri- 
 tonitis. In the chronic stages the hot douche, hot hip- 
 baths, and blisters in the iliac regions are valuable. 
 Bromide and iodide of potassium are recommended by 
 many. Courses of baths at various watering-places are 
 sometimes of value. 
 23 
 
V 
 
 354 AFFECTIONS OF THE FALLOPIAN TUBES. 
 
 It is of the greatest importance to attend to the patient's 
 general condition and, especially, to combat neurotic com- 
 plications. Sometimes the Weir Mitchell treatment gives 
 great benefit. In some cases operative procedures are 
 necessary. In non-cystic salpingitis it is often advisable 
 to remove the affected part, along with the corresponding 
 ovary. This operation must not be too quickly decided 
 upon, and a thorough investigation should be made to 
 determine how much of the patient's suffering is actually 
 due to the disease and how much to neurosis. 
 
 It has been noted in a good many cases that the patient 
 is no better after the operation. Here undoubtedly the 
 pain is largely a neurotic element. The operation is carried 
 out as follows : — 
 
 (a) By abdominal section. — The general technique has 
 already been described (p. 270). The abdominal incision 
 is madt!, 3 or 4 in. in length, between the umbilicus and 
 pubes, in the middle line or slightly to one side. The 
 operator then introduces a couple of fingers, finds the 
 fundus uteri, passes them outwards on each side to examine 
 the condition of the appendages. 
 
 If no adhesions exist, the diseased tube and ovary are 
 raised to the abdominal incision. If slight adhesions are 
 attached to the appendages, they may easily be broken down 
 with the fingers. When abundant or strong adhesion? exist, 
 there is danger of tearing some structure to whicl^ they are 
 attached, e.g. bowel, if the operator attempt to break them 
 forcibly without first exposing the parts so that they are 
 visible. In such a case the abdominal incision should be 
 enlarged, and an assistant should carefully mov i the bowels 
 aside from the region of the broad ligament, while the 
 operator divides the adhesions with the fingers, with a knife 
 handle, with the end of closed forceps, or with scissors. If 
 any bands are long enough to allow a catgut ligature to be 
 applied, they should be ligatured and cut. 
 
 Sometimes it may be impossible to get at the parts with- 
 
PYOSALPINX. 
 
 355 
 
 out enlarging the abdominal incision and turning out the 
 intestines. Great care should be taken in doing this. They 
 should not be pinched nor pressed upon in any way. They 
 should not be allowed to get cool or to dry. It is best to 
 cover them carefully in towels wrung out of hot sterilised 
 salt solution. An assistant should attend to the renewal of 
 these as long as the intestines are outside the peritoneal 
 cavity. 
 
 In this way access to the pelvis is easily obtained. If 
 illumination be required, light from the window may be 
 reflected into the abdomen by means of a mirror held 
 by an assistant, or an electric lamp may be employed. In 
 the separation of adliesions care must be taken not to injure 
 bladder, ureter, bowel, or any large vessel. 
 
 When the appendages on both sides require to be 
 removed, and if bad adhesions exist bilaterally, it is best to 
 break them down on both sides preliminary to removing 
 the appendages. This is safer than to remove them on one 
 side and then to break down the adhesions and remove 
 the appendages on the other side, because when the latter 
 method is adopted there is always danger of loosening the 
 first applied ligature by the manipulations necessary to free 
 the tube and ovary on the opposite side. 
 
 In some cases the adhesions may be so numerous and 
 dense that it is impossible to free the appendages so as to 
 remove them. In other cases, only partial separation can be 
 carried out, so that removal of but part of the appendages 
 can be effected. 
 
 When the tube and ovary can be made free from adhe- 
 sions, they are raised towards the abdominal incision. The 
 broad ligament is then pierced below the ovary with a 
 pedicle needle, carrying a silk or No. 4 catgut ligature, about 
 2 ft. in length, the eye of the needle being placed at the 
 middle of the ligature. In piercing the broad ligament, no 
 vessel should be injured. The needle is then withdrawn. 
 In the great majority of cases, the Staffordshire knot may 
 
V 
 
 356 AFFECTIONS OF THE FALLOPIAN TUBES. 
 
 be used to secure the pedicle {^ide p. 266). If the pedicle 
 be thick or tense, interlacing sutures should be employed 
 {;vide p. 267). Before tightening the ligature, the tube 
 should be well lifted up, in order that as much of it as 
 possible may be embraced. After the knot is made, a pair 
 of forceps is applied to each side of the pedicle, about | in. 
 outside the ligature. An assistant then holds an absorbent 
 pad under the forceps, and keeps the intestmes and 
 abdominal walls aside, while the operator cuts across the 
 pedicle outside the attached forceps. The stump is care- 
 fully sponged. If there be no bleeding, the ends of the 
 ligature are cut away, the forceps are removed, and the 
 stump sinks into the pelvis. 
 
 If, after cutting through the pedicle, there be bleeding, or 
 if the operator be in doubt as to the security of the ligature, 
 two ends are again passed around the pedicle under the 
 forceps, and tied, before being cut short. 
 
 If the appendageii on the opposite side are to be removed, 
 they are treated in tho same manner. If any bleeding has 
 occurred from separation of adhesions, the pelvis is sponged 
 carefully with hot pads. Sometimes irrigation with hot 
 sterilised salt solution may be required. After-drainage may 
 be necessary if there be continued oozing. The abdomen is 
 closed, as described on p. 276. 
 
 {b) By anterior colpotomy, — Recently this operation has 
 been recommended in place of abdominal section. The 
 operation is performed as described on p. 295. When the 
 peritoneum is opened, the appendages are examined, freed 
 from adhesions, and remo/ed, the pedicle being ligatured 
 exactly as when abdominal !;ection is performed. 
 
 {c) By posterior colpotomy. — The removal may be some- 
 times more easily carried out by this method. 
 
 When there are cystic conditions of the tube, e.gs, 
 pyosalpinx, -tubo-ovarian abscess, etc., removal of the 
 diseased parts should be carried out. 
 
 {a) By abdominal section, — On opening the abdomen the 
 
 I \ 
 
PYOSALPINX. 
 
 357 
 
 str te of both appendages is examined. If both are adherent, 
 and if the adhesions can be broken down easily, this should 
 be carried out before one tube is removed. The greatest 
 care must be exercised in separating adhesions, to; such 
 cases, too small an abdominal incision should not be used. 
 Plenty of room and free access are necessary. If, on exam- 
 ination, it is found that the adhesions cannot be broken 
 without great danger of rupturing the cyst, the contents 
 should be removed by means of an aspirator, care being 
 taken that no drops of fluid escape into the peritoneal 
 cavity. As soon as the aspirator is removed, the opening 
 is closed with forceps, the tube drawn up into the abdominal 
 opening, and adhesions separated. 
 
 Whether the tube be emptied or not before removal, the 
 pedicle is secured just as it is when non-cystic diseased tubes 
 are removed. After the sac is cut away, if the case be one 
 of pyosalpinx, it is important to cauterise the stump of the 
 tube outside the pedicle. This may be done with a galvano- 
 cautery or with carbolic acid. 
 
 In cases where the cystic tube cannot be removed on 
 account of adhesions, either of the following plans may be 
 adopted : — 
 
 First, if the tube be fixed low down in the pelvis, behind 
 the uterus, so that it may be opened through the vagina, the 
 abdominal wound should be closed. After this is thoroughly 
 healed, the cyst may be opened througn the posterior fornix 
 and drained. Vaginal antiseptic douches should be con- 
 tinued until the sac closes. 
 
 Second, if the tube be fixed high, so that the abdominal 
 wall can be brought near it, the cyst should be aspirated, 
 then stitched to the peritoneal edges of part of the ab- 
 dominal wound, a portion of the cyst wall being drawn into 
 the wound if possible. The rest of the wound should be 
 then closed. The opening into the cyst is enlarged, iodo- 
 form or naphthalene powder introduced, and drainage con- 
 tinued by means of iodoform gauze or a glass tube. The 
 
358 AFFECTIONS OF THE FALLOPIAN TUBES, 
 
 cyst cavity should be washed out each day with a solution 
 of formalin (i in 3000). The cavity gradually diminishes 
 in size. A sinus may remain for a long time. 
 
 {b) By anterior colpotomy. — Some operators employ this 
 method, but it \\. best to try it only when the tubes are not 
 much distended. They may be got out without aspiration, 
 though sometimes this may be necessary. 
 
 {c) By posterior colpotomy. — This method may be adopted 
 
 when the distended tube lies 
 in the pouch of Douglas. 
 
 Treatment of various dis- 
 eased conditions of the appen- 
 dages by vaginal hysterectomy 
 and removal of the diseased 
 portions, — In recent years this 
 operation has come into favour 
 in many quarters. Landau, 
 one of the chief advocates of 
 this method, sums up the 
 indications for the operation 
 as follows : — 
 
 Where there is bilateral 
 
 FIG 96.-Va8inal extirpation of ^^^ ^-^j^ ^^^ formation 
 
 the uterus. This figure repre- ' 
 
 iients the circular flap of mucosa of pus saCS, With Or without 
 
 covering the vaginal portion of fistulous Openings, intra- Or 
 
 the cervix pushed up, and forceps extraperitoneal abscesses, the 
 
 applied to the uterine artery of . , 1 i 1 • i 
 
 each side.-DuNN. Operation should be carried 
 
 out; the object being to re- 
 move as much as possible the walls of the abscesses per 
 vaginam. 
 
 In some cases, where the extent of the disease, or the 
 possibility of entirely removing it, cannot be made out by 
 bimanual examination, it may be necessary, first of all, to 
 perform an abdominal section. In such cases, owing to 
 the adhesion or high position of the tubes, it may be 
 necessary to free them before going on with the vaginal 
 
 (\ 
 
'. ; 
 
 PYOSALPINX. 
 
 359 
 
 operation ; or in some cases it may be advisable to remove 
 the tubes by the abdominal incision. In all these cases, 
 however, the uterus must be extirpated by the vaginal 
 method. 
 
 When it is probable, though not certain, that the complete 
 extirpation of all the diseased tissues is possible by way of 
 the vagina, the removal should be begun from below ; if 
 necessary, an abdominal 
 opening may be made 
 to aid the completion 
 of the operation. 
 
 In some cases this 
 operation may be carried 
 out according to the plan 
 already described. Or 
 it may be performed 
 by the use of forceps 
 and morcellement. Re- 
 cently, Richelot's and 
 Doyen's methods have 
 come into favour. These 
 
 are exceedingly valuable Fig. 97. —Vaginal extirpation of the uterus. 
 and rapid procedures. This figure represents the uterus being 
 
 grasped with forceps, and split in the 
 
 middle line. — Dunn. 
 
 A. B. Forceps. 
 
 C. Opening into the peritoneal cavity. 
 
 Richelot-Doyen oper- 
 ation. — The patient is 
 prepared as described 
 on p. 249, and is placed 
 in the lithotomy position. The uterus is curetted and then 
 drawn down. An incision is made through the mucous 
 membrane surrounding the cervix close to the fornix vaginae. 
 The tissues are then pushed up with the fingers until the 
 uterine arteries are felt. These are grasped in forceps, 
 their points being directed towards the uterus, in order not 
 to catch the ureters, and the arteries are then divided 
 between the forceps and uterus. The separation of the 
 tissues is then continued upward, and the peritoneum 
 
36o AFFECTIONS OF THE FALLOPIAN TUBES. 
 
 opened in front and behind. The bladder is kept out of 
 the way with an anterior retractor. By splitting the anterior 
 wall of tic uterus from below upwards, forceps can be 
 applied to the cut edges, and it can be thus more firmly 
 held and manipulated. 
 
 As the uterus is pulled down its fundus should be 
 anteverted, until the fundus and upper edge of the 
 broad ligament is reached. A pair of forceps is then 
 
 directed from 
 above, downwards, 
 so as to clamp the 
 upper part of the 
 broad ligament. 
 This pair should 
 overlap the pair al- 
 ready placed in 
 position. The 
 uterus may then 
 be cut free on that 
 side, pulled down, 
 and forceps placed 
 on the upper part 
 of the broad liga- 
 ment of the op- 
 posite side ; the 
 organ may then be 
 completely cut 
 away. 
 
 The posterior 
 vaginal wall often bleeds freely. The peritoneal and vaginal 
 edges should be brought together with small forceps, and 
 the haemorrhage stopped. The edges of the broad ligament 
 should then be examined, and forceps placed on each bleed- • 
 ing point, or a pair of long-bladed forceps should be placed 
 close to those already in position. In all cases where it is 
 possible, the appendages should be removed with the uterus. 
 
 Fig. 98, — Vaginal extirpation of uterus. This 
 diagram represents the clamp being placed 
 on the upper part of the broad ligament. — 
 Dunn. 
 
 U. Uterus. 
 
 O. Ovary. 
 
 Tr. Fallopian tube. 
 
 Pc. First pair of volsellae. 
 
 L.L. Broad ligament. 
 
 Ps. Second pair of volsellae. 
 
 |\ 
 

 \ ' 
 
 ff/EMA TOSAL PI NX. 
 
 361 
 
 Complications. — Sometimes the uterus is too large to 
 allow the fundus to be anteverted. In such a case the 
 cervix may be amput'^.ted. If this is not sufficient, both 
 walls may be split vertically in the middle line, the edges 
 being held with forceps. Then each half may be pulled 
 down, and the ligaments successively clamped. If the 
 ovaries cannot be drawn downward, so that the clamp may 
 be placed outside them, they must be left, the broad liga- 
 ment being clamped internal to them. 
 
 After-treatment. — If drainage is necessary, e.^. where a 
 purulent mass is opened into, iodoform gauze is used. It 
 is placed between the forceps, just entering the peritoi.ial 
 cavity. The vagina is packed between and around the 
 forceps, in order that the latter may not injure the walls. 
 
 The bladder is then drained. Antiseptic wool is placed 
 over the vulva, and kept in position with a y-bandage. 
 The patient is placed in bed, a bolster being placed between 
 her thighs, so as to support the projecting ends of the 
 forceps. 
 
 The forceps are removed in forty-eight hours. On the 
 third day an enema is given. The vagin?. and vulva are 
 dressed daily, lu three weeks the patient may begin to sit 
 up in bed. 
 
 \ 
 
 H/*:morrhage into the Tubes. 
 
 Small haemorrhages may take place in acute febrile con- 
 ditions, e.g. typhus, in purpura, in heart, renal, and hepatic 
 diseases. These are of no practical importance. 
 
 H.EMATOSALPINX. — Etiology. — Distension of the tube 
 with blood may take place as a result of atresia in the uterus 
 or vagina. It is believed by many to be a reflux from the 
 uterus of the menstrual discharge. The nearer the tube 
 the atresia, the sooner is the haematosalpinx formed. In 
 hymeneal atresia the condition is rarely observed (Bandl). 
 Some think that the blood is derived from the congested 
 
362 AFFECTIONS OF THE FALLOPIAN TUBES. 
 
 mucosa of the tubes. In these cases the tubes are usually 
 unequally distended, sometimes only one is afifected. 
 
 Against the reflux theory is the fact, that often the inner 
 end of the tube may be completely closed off from the 
 uterine cavity. 
 
 Haematosalpinx may develop in connection with the rudi- 
 mentary horn of a malformed uterus, or in the cas(; of a 
 bicornuate uterus where atresia exists on one side. It often 
 forms in connection with a tubal pregnancy. 
 
 Pathology. — Small amounts of blood may be absorbed. 
 If the tube distends, the wall gets thinner, though it may be 
 thickened in places by inflammatory changes, which usually 
 take place on the outside, leading to adhesions. The blood 
 remains fluid for a long time, probably owing to its mixture 
 with the tubal secretion. After a time it is a dirty brown 
 fluid. Rupture may take place into the peritoneal cavity, 
 or into structures with which it is adherent. Rarely 
 gangrene of the sac or suppuration of the contents takes 
 place. 
 
 In the cases in which tubal pregnancy is the cause the 
 ovum may be entirely broken up and diffused through the 
 blood, or it may be partly or entirely detached and become 
 incorporated with the blood mass to form a mole. The 
 amount of blood extravasated varies in these cases. Often 
 there is a tendency for the mass to increase, owing to fresh 
 haemorrhages succeeding the primary loss. Sometimes the 
 blood may be limited to the decidua and chorion, and may 
 be so great as to compress and almost close the amniotic 
 cavity, the foetus being partly or entirely destroyed. 
 
 In the early stages of these changes the ovum looks like 
 a fresh blood clot, and unless the specimen be studied with 
 care, the distinctive gestation tissues, e.g. amnion, chorionic 
 villi, and decidua, may not be re< tgnised. Later, the mass 
 becomes paler and firmer, undergoing the ordinary changes of 
 blood clot. They tend gradually to shrink in size, but may 
 remain as small hard masses for long periods. Suppuration 
 
 \\ 
 
TUBERCULOSIS OF THE TUBES. 
 
 ' \ 
 
 363 
 
 may sometimes follow. It is important to note that in a 
 certain number of these cases, where the clinical evidence 
 points strongly to ectopic pregnancy, the most thorough 
 examination of the tubal contents may fail to reveal cor- 
 roborative evidence. 
 
 Diagnosis. — There is nothing distinctive in the symptom- 
 atology of hjematosalpinx, it is so often associated with 
 other conditions. The physical examination givei? the same 
 results as in the case of pyo- and hydrosalpinx. The 
 enlargement is the same as these. 
 
 Treatment. — The same as for hydro- and pyosalpinx. 
 
 Tuberculosis of the Tubes. 
 
 This has been well described by Whitridge Williams. 
 The tubes are the most frequent seat of tuberculosis of the 
 genitals, according to this author ; it is generally associated, 
 however, with similar disease in the uterus or ovaries, or 
 in both. Often the peritoneum is also involved. 
 
 Tubal tuberculosis is mostly secondary to disease elsewhere, 
 though generally primary as far as the genitals are concerned. 
 Sometimes it may be primary as regards the whole body. 
 
 The disease is met with in the miliary, the chronic diffuse, 
 and the chronic fibroid forms. 
 
 The appearances presented by the tubes vary greatly. In 
 marked cases the tubes are enlarged, the outer end usually 
 being occluued ; tubeicles are on the surface, and there are 
 adhesions to surrounding structures. The lumen contains 
 yellow caseous matter, sometimes thick, sometimes fluid- 
 like, sometimes partly calcified. In old cases the inner 
 surface is raw and ragged, and studded with tubercles. 
 Rarely the muscular part of the wall is affected. The wall 
 is usually thickened by inflammatory hypertrophy. The 
 tubes are often sausage-shaped, and may fall behind the 
 uterus. They may be very firm to the touch, or may be 
 somewhat cystic. 
 
364 AFFECTIONS OF THE FALLOTIAN TUBES. 
 
 ( 
 
 In slighter cases the tubes may not be much thickened, 
 and the tubercles may not be numerous. These are most 
 numerous towards the outer end of the tube, especially 
 where there is phthisis or a peritoneal affection. 
 
 Sometimes there is a single nodular enlargement, formed 
 of several iuibercles. Sometimes the tubercular trouble may 
 be so slight that it may be missed on ordinary microscopic 
 examination. Sometimes there may be a condition of tubo- 
 ovarian abscess. 
 
 In the cases in which the disease is primary in the tubes, 
 it may be found localised there ; and though there be sur- 
 rounding peritonitis, this may be non-tubercular. 
 
 Diagnosis. — -There is no distinct method by which the 
 condition can be definitely diagnosed. The symptoms may 
 be masked by those due to tuberculosis elsewhere. Or they 
 may be simply those of pelvic inflammation, 
 
 Treatment. — Prophylactic. — As tubercle bacilli may enter 
 by the vagina, physicians and nurses should make digital 
 examinations in the most cleanly fashion. 
 
 Women should not sleep near a source of tubercular 
 infection, and should avoid coitus with diseased men. 
 
 General. — If the case be one of widespread tuber- 
 culosis, the treatment is directed towards the general 
 condition. 
 
 Operative. — If the tubes are diagnosed they should be 
 removed, provided there is no disease elsewhere, or if 
 there is only a slightly marked degree in the lungs. If, 
 on opening the abdomen, the peritoneum be widely affected, 
 the tubes should be removed. Where the uterus is affected, 
 along with the tubes and ovaries, it is doubtful if Hegar's 
 suggestion of removal of all these parts should be under- 
 taken. Possibly most will prefer to remove the tubes and 
 ovaries and to curette the uterus, applying iodoform to its 
 cavity. 
 
 In the above operations, the ovaries are to be taken away 
 with the tubes. 
 
NEW GROWTHS OF THE TUBES. 
 
 365 
 
 Actinomycosis of the Tubes. 
 
 This may be primary and due to infection from without, 
 or may be secondary to the affection elsewhere. The tube 
 becomes enlarged and adherent to surrounding structures. 
 Nodules of the growth are found in the wall, and the lumen 
 of the tube gets distended with pus. Secondary abscesses 
 may result from the tubal condition. 
 
 New Growths of the Tubes. 
 
 Carcinoma. — This is sometimes primary. It arises in the 
 mucosa, and may be of the papillomatous or adenomatous 
 type. It is mostly found on one side. The ovary is some- 
 times affected as well. It may lead to closure of the outer 
 end of the tube. Inflammatory changes may be present. 
 In fourteen cases, only one was belovv the age of 40. The 
 rest varied from 43 to 60 (Sanger and Barth). 
 
 Secondary infection may be due to direct spread from 
 ovary or uterus. It may appear in the mucosa or in the 
 outer part of the wall first, and may be papillary, adenoma- 
 tous, medullar/, or scirrhous in type. 
 
 The cancerous masses may be found in nodules, or 
 diffused. 
 
 Diagnosis. — At first the symptoms may in no way be 
 distinguishable from those of salpingitis. Later, ascites 
 usually develops and cachexia. 
 
 Sarcoma. — This is very rare indeed as a primary condi- 
 tion. It may form a diffuse mass or a series of projections 
 in the tube. Sometimes the epithelial elements may show 
 changes, so that a kind of carcino-sarcoma is produced. 
 Sometimes sarcoma may spread from the uterus along the 
 tubes. 
 
 Papilloma is sometimes found, non-malignant. It may 
 be cystic. 
 
 Myoma, fibroma, and lipoma are very rare. 
 
 (1(1 
 
^ 
 
 366 AFFECTIONS OF THE FALLOPIAN TUBES. 
 
 Simple cysts and cystic m} jmata may develop under the 
 peritoneal covering, and are probably derived from Wolffian 
 remains. Cysts are also found at the fimbriated end, and, 
 rarely, fibromyxoma. 
 
 Dermoid cysts of the tube wall are extremely uncommon. 
 
 PoljHpi of the tube may be formed by carcinomatous, 
 sarcomatous, or papillomatous growths ; by inflammatory 
 changes ; as a result of decidual changes ; haemorrhage into 
 a limited portion of the mucosa. 
 
 Treatment. — When new growths of the tube are of such 
 a size or nat'ire as to cause trouble, the tube should be 
 removed either by abdominal or vaginal section. 
 
 Di^erential Diagnosis of Tubal Enlargements. 
 
 1. Broad ligament tumours. 
 
 2. Ovarian swellings. 
 
 3. Tubal or cornual pregnancy. 
 
 4. Inflammatory or haemorrhagic effusions in the pelvic 
 peritoneum or cellular tissue. 
 
 5. Retroflexion of the uterus. 
 
 6. Subperitoneal uterine fibroid. 
 
 7. Retained blood in a malformed uterus. 
 
 8. Faecal masses in the rectum. 
 
 9. Cancer of the sigmoid flexure. 
 
 10. Burrowing perityphlitic abscess. 
 
 11. Kidney displaced into the pelvis. 
 
-v 
 
 CHAPTER XIII. 
 
 ',:<i 
 
 ;!'ii 
 
 AFFECTIONS OF THE OVARIES. 
 
 Anomalies. 
 
 
 Sometimes both ovaries are congenitally absent ; this is 
 associated with defective development in the uterus. Some- 
 times one ovary may be wanting ; the corresponding tube is 
 usually absent, and sometimes the corresponding half of 
 the uterus ; occasionally the kidney on the same side is 
 wanting. 
 
 The ovaries may vary considerably in size, sometimes 
 being very small. In some cases the ovary is divided by 
 a deep fissure, so that one part is almost isolated. 
 
 These fissures may be congenital, or they may be caused 
 by inflammation. 
 
 Supernumerary ovaries have long been described, but the 
 work of Bland Sutton seems to show that they probably fall 
 under the above category, and that there is no proof that 
 accessory ovaries apart from the main gland exist. He 
 thinks that small fibroids in the broad ligament may have 
 been wrongly described as such. 
 
 li 
 
 Hernia of the Ovary. 
 
 The ovary alone, or with the tube, omentum, uterus, or 
 intestine, may occupy a hernial sac. 
 
V. 
 
 368 
 
 AFFECTIONS OF THE OVARIES. 
 
 In the inguinal canal. — ^This is the most frequent variety, 
 but it is a rare occurrence. 
 
 According to some, it is doubtful if reported congenital 
 cases are of the nature described ; in these instances it is 
 thought likely that the female is possessed of testes which 
 have entered the inguinal canal. 
 
 An acquired hernia may occur at any age. Strangulation 
 may occur, and symptoms produced like those in conditions 
 of strangulated epiploceles or enteroceles. Possibly the 
 symptoms may be produced by twisting of the pedicle. 
 Apart from strangulation, there may be distress or pain 
 in the inguinal region, worse at menstrual periods, and 
 sensitive on pressure. The ovary usually becomes ad- 
 herent. 
 
 As to treatment, nothing may be needed ; a protecting 
 cap may be worn, or the ovary may be taken away if the 
 pain is troublesome. 
 
 Obturator and abdominal hemiae are sometimes found. 
 
 If 
 I? 
 
 Prolapse of the Ovary. 
 
 The ovary may be variously displaced. 
 
 Etiology. — A considerable proportion of cases develop 
 after labour, when the conditions are favourable, the ovaries 
 having been enlarged and their ligaments softened. A sudden 
 fall or jump, or the lifting of heavy masses, may cause the 
 ovaries to descend. Retroversion drags them down. When 
 enlarged from any cause they tend to sink. 
 
 Inflammatory adhesions may contract and drag them 
 down, or enlarged tubes which fall down may displace them. 
 
 They may be found in the following situations : — 
 
 1. In the pouch of Douglas. 
 
 2. Behind the lower part of the broad ligaments. y 
 
 3. In the utero-vesical pouch. 
 
 4. In the cup-shaped c -.pression of an inverted uterus. 
 The last two are very ancommon. 
 
PROLAPSE INFLAMMA TION. 
 
 369 
 
 Diagnosis. — There is pain in the pelvis, increased on 
 coitus and defaecation. There is often much disturbance 
 of health and neurotic complications. On examining the 
 pelvis the ovaries are felt exquisitely tender. The symp- 
 toms are aggravated when inflammation is present. 
 
 Treatment. — Hot douches, glycerin tampons, and blisters 
 in the iliac regions should be tried. 1 he bowels should be 
 regulated. If the uterus be retroverted, it should be replaced 
 if possible, and kept in position with a Hodge or Albert 
 Smith pessary ; if these give rise to pain, a ring may be worn 
 for a time. 
 
 When no improvement results from these measures, 
 especially where there is ovaritis or adhesions, the question 
 of removal by abdominal or vaginal section must be care- 
 fully considered.. 
 
 Sanger has recently recommended an operation for 
 restoring the appendages to their normal level. He 
 stitches the uterus to the anterior abdominal wall, and 
 sutures the mesosalpinx to the side wall of the pelvis 
 near the brim level. 
 
 ".t;\\ 
 
 Inflammation. 
 
 Ovaritis, Oophoritis. — Inflammation of the ovary is very 
 generally associated with salpingitis. It may be acute or 
 chronic. 
 
 Etiology. — The causes are practically the same as described 
 in connection with salpingitis. It is important to note that 
 the commonest cause is micro-organismal infection. Ovaritis 
 may also be caused by arsenic and phosphorus poisoning. 
 It may be secondary to parotitis, usually developing as the 
 attack of mumps subsides ; sometimes the pelvic trouble 
 may precede the other. 
 
 Pathology. — The inflammation may particularly affect the 
 follicles or the stroma. Generally, in acute cases, the former 
 are markedly affected. The ovary enlarges; the Graafian 
 24 
 
 ^ :, 
 
370 
 
 AFFECTIONS OF THE OVARIES. 
 
 follicles swell, their contents becoming cloudy \ the cells of 
 the membrana granulosa and discus becoming degenerated, 
 the ovum breaking down and the zona pellucida getting 
 swollen and folded. On the surface the germ epithelium 
 may break down. 
 
 There is congestion of the vessels. Exudation takes place 
 in the stroma ; small ecchymoses may form. Pus may 
 develop in one or more centres, and may go on to form a 
 true abscess of the ovary. 
 
 In advanced cases the ovaries may become smaller, 
 irregular, and cirrhotic. The follicles are destroyed or filled 
 
 with turbid, thick, or bloody 
 fluid. 
 
 An ovarian abscess may 
 reach the size of an egg, or 
 more rarely may reach the 
 size of a child's head. It 
 may rupture spontaneously 
 into the intestine, bladder, 
 vagina, or through the ab- 
 FiG. 99.— Chronic ovaritis, with small dominal wall, and improve- 
 
 cyst-like distensions of Graafian j^ent in symptoms follows 
 follicles. ,, • T> 1 
 
 this occurrence. Rarely, 
 it may rupture into the peritoneal cavity. Sometimes an 
 ovarian abscess may communicate with a purulent tube 
 {vide^. 351). 
 
 Periovaritis may be primary or secondary to ovaritis, or 
 associated with it. Adhesions are formed over the ovary, 
 sometimes as strings or bands which may connect it with 
 the broad ligaments, tubes, or pouch of Douglas ; rarely with 
 the uterus or intestines. Sometimes, thick capsules may be 
 formed around the ovary. As a result of traction on a small 
 band of adhesion the ovary may be deeply fissured. V 
 
 Diagnosis. — The symptoms in acute ovaritis are practically 
 the same as in acute localised peritonitis. There is sharp 
 pain in the region of the ovary, which radiates. On examina- 
 
PER 10 VARITIS. 
 
 yi^ 
 
 or 
 
 ina- 
 
 tion, the ovaries are very painful to the touch, and may be 
 felt to be somewhat enlarged. 
 
 In chronic ovaritis the symptoms are much the same as 
 in chronic salpingitis. There is the same tendency to the 
 development of ill -health and of neurotic manifestations. 
 Sterility is often the result of double ovaritis. There is 
 generally menorrhagia, often metrorrhagia, sometimes scanty 
 menstruation. The dysmenorrhoea may last through a whole 
 period, but is most marked during the first two or three 
 days. 
 
 In cases of abscess, there are usually the ordinary symp- 
 toms of this condition. 
 
 On physical examination, one side is usually worse than 
 the other. The affected part is tender. It may be felt 
 somewhat enlarged and irregular ; or small, irregular, and 
 hard. 
 
 Treatment. — The same as in the case of salpingitis. In 
 severe cases operative measures must be carried out, but the 
 greatest care should be taken to ascertain that the need 
 exists, and that the patient's sufferings are not mainly 
 neurotic. 
 
 The operative treatment of inflamed ovaries is of three 
 varieties : — 
 
 1. Puncture and destruction of small cysts formed in 
 certain cases. 
 
 2. Resection of a diseased part. 
 
 3. Complete removal. 
 
 Puncture. — Anterior colpotomy or abdominal section is 
 performed, the ovary is freed from adhesions, and the small 
 cysts which are present are punctured, and destroyed by 
 means of a galvano-cautery. 
 
 Resection.— h.vA.Qx\Q>x colpotomy or abdominal section is 
 performed, and the diseased part of the ovary is cut out. 
 The raw surfaces are then brought together by means of 
 fine catgut sutures (No. i). 
 
 Probably in all cases in which pu.icture or resection is to 
 
372 
 
 AFFECTIONS OF THE OVARIES. 
 
 be carried out, the vaginal incision should be employed, 
 unless the vagina be too small. ' i -^ ■ ■ 'f hj 
 
 Removal. — When an inflamed ovary requires removal, the 
 tube is taken away with it, since inflammation is so com- 
 monly present in it also. This operation is termed salpingo- 
 oophorectomy. I have already described it in connection 
 with salpingitis (p. 354). It is carried out either by means 
 of abdominal or vaginal section. 
 
 -;l 
 
 Tumours of the Ovary. 
 
 Cystoma. — Modes of origin. — The sources of the various 
 cysts which are found in the ovary are generally given as 
 follows : — 
 
 1. Distension of Graafian follicles. The small simple 
 cysts arise in this manner. . , 
 
 2. Degeneration jf young undeveloped follicles. Most 
 multilocular cysts are believed to arise in this manner. 
 
 3. Development of remains of the Wolffian body in the 
 hilum of the ovary. The papillomatous cysts arise in this 
 way. 
 
 4. Colloid degeneration of ovarian stroma. 
 
 5. Certain embryonic cellular rods, in the cortical layer, 
 probably derived from the germinal epithelium ; some 
 believe them to be degenerated blood vessels. 
 
 G. Malignant disease. 
 
 7. Of dermoid nature. .. s > i 
 
 Varieties Considered in Detail. 
 
 Simple cysts. — The commonest of these is the small 
 hydrops folliculorum, due to the distension of Graafian 
 follicles. Several may be found in the same ovary, and 
 they are often associated with inflammatory changes in the 
 ovary. These cysts may be small, or may project from 
 the surface. The contents are usually thin, serous, and 
 
 W 
 
SIMPLE CYSTS. 
 
 373 
 
 w 
 
 ( ; 
 
 '-.( 
 
 light- coloured, sometimes brownish. The cyst is lined 
 with cells derived from the membrana granulosa. Some- 
 times the ovary is permeated with these cysts, the stroma 
 being gradually obliterated. 
 
 Rarely a single cyst may develop as large as an egg, 
 an orange, or a head. Sometimes the same ovary may be 
 the seat of two or three la.ge cysts, or both ovaries may 
 show the change. They are independent of one another, 
 and one does not grow from the other, as in the case of 
 the multilocular cyst. Sometimes the walls between these 
 may break down. The walls of these are generally thinner 
 than in proliferating cys- 
 toma. They are composed 
 of fibrous tissue, and are 
 lined with low cylindrical 
 epithelium. The cyst con- 
 tains thin serous fluid, with 
 a sp. gr. of 1005 to 1020. 
 Rarely blood or pus is 
 found in it. 
 
 The causes of the dila- 
 tation in these cases is not 
 known. Possibly, sometimes 
 the corpus luteum may be 
 the starting-point of a cyst. Ordinarily these small cysts 
 have no significance. Large ones require to be removed. 
 
 Proliferating multilocular cystoma. — These vary greatly 
 in size and structure. They have been known to reach 
 a weight of 100 kilos. The tumour is made up of 
 numerous cysts. The smaller the tumour the more alike 
 in size are the cysts. As it grows, one cyst is apt to 
 develop more rapidly than the rest, especially one situated 
 anteriorly ; sometimes two or more cysts reach a large size. 
 In some large tumours no special enlargement occurs, all the 
 cavities remaining small, a section of the mass resembling a 
 honeycomb. 
 
 Fk;. 100. — Hydrops folliculoruni. 
 The ovary is somewhat altered by 
 inflammation, and contains several 
 enlarged follicles. 
 
V 
 
 374 
 
 AFFECTIONS OF THE OVARIES, 
 
 Fig. ioi. — Section of an ovarian 
 cyst, in which the cavities are 
 small, and filled with thick 
 colloid material. 
 
 When large and small cysts exist, the latter are found in 
 the walls of the former. They may form projections on 
 
 the outside or inside ; they may 
 sometimes rapidly develop, and 
 tend to obliterate large cavities. 
 Sometimes several cavities 
 may be joined into one, by 
 obliteratiori of intervening septa. 
 It is by this process that the 
 very large cavities are produced. 
 Occasionally a unilocular cyst 
 may be brought about in this 
 manner. 
 
 Large tumours are usually 
 more elastic than small ones. 
 The walls of the individual 
 cysts vary greatly in thickness. The outer wall is usually 
 the thickest. It is of a dulled whitish-grey appearance ; 
 when very thin, it has a 
 bluish tinge. It is not so 
 glistening as a peritoneal 
 surface. 
 
 These tumours are pedi- 
 culated, the pedicle being 
 composed of broad ligament, 
 Fallopian tube, and ovarian 
 ligament. 
 
 Structure. — The outer sur- 
 face is covered with low 
 cubical or flattened epithe- 
 lium, the remains of the 
 germinal epithelium. The 
 main mass of the wall is 
 
 fibrous, and may be arranged in one, two, or three layers. 
 Near the pedicle smooth muscular fibres are found. The 
 inner wall of the cysts is covered with columnar or cubical 
 
 Fig. I02. — A small ordinary multi- 
 locular cystic ovarian tumour. 
 The relation to the broad liga- 
 ment is shown. 
 
 / ■, '. 
 
 h 
 
CYSTOMA. 
 
 375 
 
 \> 
 
 Fk;. 103. — Section through 
 portion of a multilocular 
 cyst. 
 
 a small 
 ovarian 
 
 epithelium, usually arranged in a single layer ; sometimes 
 these cells are very large and translucent on account of the 
 mucus they contain. 
 
 Sometimes solid masses may be found in the walls, pro- 
 jecting into the cavities. These are generally thickenings of 
 the stroma, and may be 
 myxomatous or fibrosar- 
 comatous. Sometimes the 
 proliferating cystoma is 
 associated with the papil- 
 lomatous growth next to 
 be described. 
 
 Certain changes may 
 occur in the walls. Cal- 
 cification takes place some- 
 times as a deposition in the 
 form of granules or plates. 
 It is the more apt to occur as the nutrition of the tumour is 
 affected, e.g. after torsion. Sometimes it may occur in the 
 epithelium or in the cyst contents. 
 
 Fatty degeneration is common, especially in the epi- 
 thelium lining the cysts ; it may also occur in the walls, 
 especially in the septa. This change is favoured by impaired 
 
 nutrition. Atheromatous changes 
 may be also found, and infarcts some- 
 times occur. 
 
 The contents of these tumours vary 
 considerably. They are generally 
 viscid, ropy, glairy, gelatinous, or 
 colloid. The specific gravity varies 
 from ioiotoioi3. Often as the cysts 
 grow very large their fluid becomes thinner. The gelatin- 
 ous masses in the smaller cysts are often very tough and 
 are removed with difficulty from the wall. Sometimes the 
 partitions between a number of these small masses may 
 degenerate, and large portions of the gelatinous substance 
 
 Fig. 104. — Columnar cells 
 lining wall of ovarian 
 cyst. 
 
V. 
 
 376 
 
 AFFECTIONS OF THE OVARIES, 
 
 may show the remains of these as whitish lines running 
 through it. Sometimes altered blood may be mixed with 
 the contents ; in certain conditions pus may be present 
 also.. 
 
 The chemical reaction is neutral or alkaline. The solids 
 vary from 50 to 100 parts per 1000, and consist of proteids, 
 fats, and salts ; sodium chloride is the most abundant salt ; 
 alkaline and earthy phosphates are also found. Choles- 
 terin is sometimes present. Other salts, e.g. leucine, urea, 
 cystin, allantcin, are sometimes found. The proteids con- 
 sist of metalbumin, paralbumin, and 
 other derivatives, probably, of true 
 albumin. Mucin is also present. 
 
 Epithelial cells, more r - less de- 
 generated, may be found in <:he fluid ; 
 granular masses, blood corpuscles, 
 granules of pigment, leucocytes, pus 
 cells, cholesterin. There are no 
 pathognomic cells. 
 Fig. 105. — Papilloma- Papillomatnus cysts. — These are 
 tous cyst, growing ^f^g^ bilateral, and do not generally 
 
 from the hilum of . ' ,. 7 ., , 
 
 ovary, and expending reach the Size of ordmary multilocular 
 
 into the broad liga- cysts. They are generally developed 
 
 "^^"'* from the hilum of the ovary. 
 
 The number of cavities is small ; there is often only 
 
 one. On the inner wall are papillomatous growths, 
 
 arranged as densely massed nodules, or as detached 
 
 branching nodules, from the size of a pea to that of a 
 
 nut, rising from a pedicle. They vary in colour from 
 
 white to red ; sometimes they are hard from calcareous 
 
 deposition. 
 
 The larger a cyst, the smaller the proportion of papillom- 
 atous growths it is apt to contain. Some small cysts may 
 be entirely filled with them. Usually a bit of the ovary is 
 found in the outer wall of the tumour. 
 
 The tumours tend to grow between the layers of the 
 
 
 tv 
 
\ ■ . 
 
 PAPILLOMATA. 
 
 377 
 
 i 
 
 i> 
 
 broad ligaments, and therefore to be covered with peri- 
 toneum. The uterus is displaced by the growth, which may 
 develop under the peritoneum of the pelvic floor, or in the 
 mesentery of the sigmoid flexure or intestines. It may also 
 come into direct relationship with the bladder or abdominal 
 wall. 
 
 In cases in which the tumour does not grow extraperi- 
 toneally, it is pedunculated like the ordinary cyst. The 
 main mass of the wall is fibrous tissue. The epitli^ "SI 
 
 Fig. 106. — Section through projections on wall ot papiilonmtous cyst 
 growing in hilum of ovary. 
 
 lining is chiefly cylindrical, and for the most part ciliated ; 
 the cells vary greatly in height, in many parts being cubical. 
 The papillomata are usually covered with the cylindrical 
 cells. 
 
 The stroma of the projections is delicate connective 
 tissue. They are vascular, and bleed easily. Calcareous 
 concretions are apt to develop in the stroma of the wall 
 and in the papillje. As the papillomata grow they may 
 perforate the walls of their cysts, and extend into neighbour- 
 ing cavities. They may perforate the outside wall and 
 fasten the tumour to surrounding parts, e.g pelvic floor, 
 uterus, rectum, bladder. When rupture occurs into the 
 
378 
 
 AFFECTIONS OF THE OVARIES. 
 
 peritoneum, dissemination may take place quickly, the 
 growths continuing and growing into other organs. Hydro- 
 peritoneum accompanies the development of these secondary 
 masses. 
 
 The pouch of Douglas, the omentum, and mesentery are 
 most abundantly covered with the growths after rupture. 
 
 These tumours usually contain opaque, dirty yellowish, 
 serous fluids, not ropy nor colloid. Free portions of the 
 growths may be found in the fluid. 
 
 Sometimes papillomatous characters may be found along 
 
 with those of the proliferating 
 cystoma proper. 
 
 As to the origin of papillo- 
 matous cysts, it has generally 
 bem believed that they arc 
 derived from Wolffian remains, 
 especially found in the hiluni 
 of the ovary. There is good 
 reason for believing, as Whit- 
 F.G. io7.-Cavity of a dermoid ridge Williams states, that they 
 cyst. Two teeth, a mamma- may also grow from the ger- 
 
 like projection, and hair are ^^^^^\ epithelium, and from 
 attached to the wall. „ ^ r n- i •nvn- 
 
 Graafian follicles. W^illiams 
 thinks that sometimes they may arise from the fimbriEe of 
 the tube, which become adherent to the ovary. 
 
 Dermoid cysts. — These are the cysts in which certain of 
 the elements of the integument predominate, e.g. sebaceous 
 and sweat glands, nail, manimre, nipples, hair, teeth, etc. 
 Mucous membrane elements are also found in some. They 
 may grow to be as large as an adult head, but ordinarily 
 they are met v.-idi smaller than this. As a rule they are 
 unilateral, but they may be found in both ovaries. They 
 are almost always unilocular, but two may be found in one 
 ovary. The walls are often thick, but may be thin. The 
 inner surface may be smooth in large part, with projecting 
 skin-like portions, ^^i^. which hair grows ; it consists of 
 
DERMOID CYSTS. 
 
 379 
 
 Stratified squamous epithelium. In some cases it has the 
 structure of a mucous membrane, being lined with columnar 
 epithelium and mucous glands. 
 
 Bones and teeth are not constant constituents. The 
 former are situated in the connective tissue of the wall ; 
 sometimes pieces of bone are connected by joints. The 
 teeth are in the connective tissue, but may project into the 
 cavity ; they may be fixed in bony plates. The crowns 
 usually slope towards the median plane of the body. Occa- 
 sionally a milk-tooth may be found in course of absorption, 
 another growing beneath it. 
 Grey matter of the central ner- 
 vous system has been found; 
 rarely, medullated nerves. 
 Sometimes nerves can be traced 
 from the grey matter to bone 
 and other tissues. 
 
 Nail is very rarely found. 
 Hair is often found of great 
 length. It may be white in 
 elderly people. It tends to be 
 shed and to lie in the cavity. 
 
 The sebaceous glands may 
 give rise to wens, and " horns " 
 may grow from them. Nipple-like projections are oc- 
 casionally found, sometimes surrounded with an areola. 
 Rarely these may be associated with small mammae, which 
 may produce colostrum. Bland Sutton has found a 
 thyroid gland ; Virchow has described smooth muscular 
 fibres. 
 
 The dermoid usually contains a thick oily material, con- 
 taining fat, epidermic cells, hairs, and sometimes cholesterin. 
 On removal from the body the fat hardens. In it are some- 
 times found "epithelial pearls," formed of shed masses of 
 concentrically arranged epithelial cells. 
 
 When mucous membrane lines a cyst, it may secrete 
 
 Fu;. io8. — Section through wall 
 of a dermoid cyst. The skin- 
 like character of the inner wall 
 is shown. 
 
V 
 
 38o 
 
 AFFECTIONS OF THE OVARIES. 
 
 mucus. Some dermoids may contain no fluid. There may 
 be retention cysts derived from the sweat glands. 
 
 Sometimes colloid degeneration is found in the stroma of 
 a dermoid. 
 
 A dermoid and a proliferating cystoma may coexist in the 
 same ovary. It may be associated with a malignant growth. 
 If a dermoid ruptures, there may result epidermal implanta- 
 tion on different parts of the peritoneum. It is generally 
 believed there is some special tendency to malignancy in 
 dermoids, but this has not been definitely established. 
 
 Doran states that he has frequently observed the growth 
 of malignant tumours in the abdomen after removal of 
 dermoids. 
 
 Theories as to the origin of dermoids. — Some believe that early 
 in foetal life, certain portions of the foetal layers, epecially the epiblast, 
 get included in the developing ovary. While the main part is epiblastic, 
 it is likely that mesoblastic elements are also included, helping to explain 
 the development of bone and muscle. 
 
 Others, e.g. Waldeyer, think that the epithelial elements in the ovary 
 may in these cases have some special formative power, producing ele- 
 ments other than epithelium. (As Olshausen points out, if this be the 
 case, the production of such a varied assortment of elements might 
 deserve the name of a " parthenogenetic development.") 
 
 Inland Sutton thinks that ' ' the epithelium of the ovarian follicle is 
 the source of all the structures found in ovarian dermoids." He makes 
 a sharp distinction between dermoids and teratomata, the latter being 
 due lo suppressed teratomata. 
 
 Olshausen, on the other hand, thinks that the development of terato- 
 mata in the ovary is due to foetal inclusion, and that there is no practical 
 genetic distinction between ovarian dermoids and teratomata. 
 
 It is important to note that an old tubal pregnancy which had under- 
 gone lithopa;dion formation, and with which the ovary has been closely 
 blended, has often been wrongly described as either a teratoma or a 
 dermoid. 
 
 Bland Sutton has pointed out that " in women dermoids have never 
 been found growing primarily from any abdominal viscns, save the 
 ovary,'''' 
 
 Development and growth of dermoids. — They are the 
 most frequent tumours in the abdomen before puberty, and 
 
PARO VA RIAN C VSTS. 
 
 381 
 
 may be met with in early childhood. The majority are only 
 recognised, however, after puberty. They may be found in 
 very old age. They usually grow very slightly in the course 
 of years. At puberty the most rapid increase occurs in 
 them. Sometimes the genitals are imperfectly developed in 
 the case of a dermoid of the ovary, but occasionally pre- 
 mature development is marked. 
 
 Peritonitis is very prone to occur around dermoids, and 
 torsion of the pedicle is common. Suppuration, gangrene, 
 and rupture of the wall may take place. 
 
 In many cases only slight pressure disturbances are 
 produced. Marked enlargement may be due to colloid 
 degeneration, to retention cysts, or to the growth of an 
 accompanying proliferating cystoma. 
 
 Broad Ligament Cysts.^ 
 
 Parovarian cysts. — Certain small cysts, rarely larger than 
 a pea, may develop with the short tubules external to the 
 
 ovary, known as Ko- 
 belt's tubes ; these are 
 of no importance. They 
 must be distinguished, 
 however, from the hyda- 
 tid of Morgagni (vide 
 
 P- 15)- 
 
 The important cysts 
 
 are formed from the 
 
 KiG. io9.-Parovarian cyst of left broad tubules of the Organ of 
 ligament. Ovary and tube are seen on ^ .... , 
 
 the wall of the cyst. Rosenmuller, between 
 
 Gartner's duct and the 
 hilum of the ovary. These cysts are almost always unilocular. 
 Only one cyst may exist, which grows to a considerable size, 
 sometimes reaching into the abdomen ; or two or three 
 small ones may exist side by side. 
 
 1 These are conveniently studied here. 
 
 m 
 
 m 
 
V 
 
 382 
 
 AFFECTIONS OF THE OVARIES. 
 
 Small cysts are translucent ; in large ones the walls thicken 
 somewhat, though it always remains a thin membrane. The 
 peritoneal covering is somewhat movable on the surface, 
 and in life is seen to contain numerous vessels. It can 
 usually be stripped off the tumour with ease. The main 
 thickness of the wall is fibrous tissue. The lining in small 
 cysts consists of columnar epithelium ciliated in parts. In 
 la^ge cysts the epithelium is compressed, and may be 
 cubical or flattened ; it may be found in more than one 
 layer. No papillary projections grow on the wall. 
 
 Fig. iio. — Coronal section of a pelvis, containing a large 
 parovarian cyst of the right broad ligament. The dis- 
 placement of the uterus is well seen. 
 
 ill 
 
 The fluid is thin and limpid and alkaline. Specific 
 gravity 1002 to 1008. It contains little proteid matter, but 
 occasionally there is paralbumin. In large cysts the fluid 
 may be turbid, and may contain cholesterin. Sometimes a 
 fluid of high specific gravity may be found. 
 
 These cysts are usually non-pedunculated, but a pedicle 
 may form, owing to the bulging of the tumour in one 
 direction. 
 
 As the cyst grovvs, the Fallopian tube is stretched over it 
 and elongated, its walls being thinned. The ovary is drawn 
 towards it, and may be closely applied to it ; it may become 
 
PAPILLOMA TOUS C YSTS. 
 
 383 
 
 greatly stretched or flattened, appearing as a mere thickened 
 portion of the cyst wall. 
 
 As the cyst develops, it burrows beneath the peritoneum 
 and may pass beneath the pouch of Douglas to the opposite 
 side, and may reach rectum, csecum, or colon. It may lie 
 in contact with bladder, uterus, and pelvic floor. Thus 
 these various structures may be considerably displaced. 
 
 The cyst grows slowly, and may be stationary for years, 
 
 
 
 Fig, III. — Section through a papillomatous cyst of the broad 
 ligament. The tumour has widely separated the layers 
 of the ligament. The ovary and tube are seen. 
 
 giving no trouble. It tends to rupture spontaneously, the 
 fluid being quickly absorbed. 
 
 The process of refilling occurs slowly after rupture or 
 puncture, e.g. months or years may elapse. Adhesions are 
 not often met with. Torsion is rare. 
 
 Time of occurrence. — These cysts are very rare before 
 puberty. A considerable proportion are met with in the 
 years following puberty, but they may be found as late as 
 the age of 60. 
 
 Papillomatous cysts. — These are unilocular, and contain 
 
 m 
 
 m 
 
 f-ili 
 
 f 
 
 |:!l 
 
n»'iS'Jsw*ri 
 
 V 
 
 384 
 
 AFFECTIONS OF THE OVARIES. 
 
 on their inner surface papillary projections, similar to those 
 described in papillomatous cysts of the ovary. 
 
 They develop extraperitoneally, as has been described in 
 the case of parovarian cysts. Their significance is the same 
 as that of papillomatous cysts of the ovary. 
 
 They originate from remains of the Wolfifian body within 
 the broad ligament. Bland Sutton thinks that some of 
 them may arise from remains of Gartner's duct. 
 
 There is one variety in which the warts are very hard, 
 
 differing from the soft vascular 
 papillary projections so character- 
 istic of the common papillomatous 
 cyst. 
 
 Various Changes in Ovarian 
 Cysts. 
 
 Torsion. — Rotation of the cyst 
 may occur, causing a twist in the 
 pedicle. This takes place in vary- 
 ing degrees, e.g. half a turn may be 
 found, or as many as five or six. 
 The causes are not well known. 
 They are said to be — the influence 
 of a growing pregnant uterus ; 
 emptying of the pregnant uterus ; sudden alterations of 
 intra-abdominal pressure, e.g. lifting, unequal growth of 
 the tumour, movements resulting from a physical examina- 
 tion. 
 
 Predisposing factors are ascites, and a long pedicle. 
 Dermoids are especially liable to torsion. Torsion inter- 
 feres with the nutrition of the tumour, and various results 
 may follow. 
 
 CEdema of the pedicle and tumour occurs, marked 
 venous engorgement, haemorrhage into the cyst wall or 
 cavities, which may cause great anaemia or death ; peritonitis, 
 leading to adhesions with surrounding structures ; in some 
 
 Fig. 112. — Outline of a 
 broad ligament cyst of 
 the right side dispiacing 
 uterus and bladder. 
 
INFLAMMATION. 
 
 385 
 
 Fig. 113. — Outline of .1 
 large ovarian cyst. The 
 irregularities due to 
 small projections of the 
 wall are shown. 
 
 cases, gangrene of the cyst. Gangrene is probably due to 
 
 the entrance of micro-organisms from 
 
 adherent bowel. 
 
 Where gangrene does not occur, 
 
 the tumour may shrink in size. 
 
 Sometimes the pedicle may be com- 
 pletely dividec. The veins throm- 
 bose, and the tissues become brittle 
 
 and tend to be easily severed. The 
 
 tumour may continue to be nourished 
 
 by means of the circulation carried 
 
 on through the adhesions; it is 
 
 doubtful if it can increase much in 
 
 size in this condition. 
 
 The tumours which have been most 
 
 frequently described as undergoing 
 
 this change are dermoids. 
 
 Sometimes the intestine may be obstructed by a twisting 
 
 tumour. 
 
 Inflammation. — Adhesions are comparatively common in 
 
 ovarian tumours. This is probably 
 due to micro-organismal infection 
 through the Fallopian tube, vermi- 
 form appendix, or bowel Tapping 
 was a frequent source in the pre- 
 antiseptic days. Adhesions may take 
 place between the tumour and the 
 parietal or the visceral peritoneum. 
 The larger the cyst the more likely 
 there are to be adhesions. Those 
 on the anterior wall are the most 
 frequent and extensive, owing to the 
 more constant pressure there. Next 
 in frequence are omental adhesions, 
 
 then intestinal, then vesical, uterine, etc. The condition of 
 
 the case is thereby rendered much worse as regards operative 
 25 
 
 Fig. 114. — Outline showing 
 the gradual increase in 
 size of an ovarian cyst. 
 
 If 
 
 % 
 
 \\ 
 
386 
 
 AFFECTIONS OF THE OVARIES. 
 
 1 
 
 treatment. There may be great risk of tearing through a 
 large vessel, e.g. the iliac, through the ureter, vermiform 
 appendix, etc., in the removal, while there may be great 
 difficulty in separating bowels from the wall. 
 
 Suppuration may occur in some cases. This is accom- 
 panied with marked formation of adhesions. Sometimes 
 the pus may escape to the exterior by one or other route. 
 Gas may develop in the cyst in connection with suppuration, 
 giving rise to a tympanitic note on percussion. 
 
 Rupture. — Rupture of an ovarian cyst may occasionally 
 
 occur. The causes vary. The wall 
 may grow very thin at one place and 
 gradually burst ; or the thinness may 
 be due to the development of second- 
 ary cysts in the main wall. In such 
 cases there may be several points of 
 perforation. Haemorrhage in the wall 
 or in the cyst may lead to rupture. 
 Thrombosis of vessels may occur, 
 followed by fatty degeneration and 
 softening, or gangrene of the wall. 
 / Suppuration within the cyst may 
 
 cause it. In papillomatous cysts the 
 Fig. 115. — Outline show- .„ , r , 
 
 ing irregular swelling in papiHary growths may perforate the 
 
 abdomen, due to faecal wall. Blows, falls, injury during 
 
 accumulation. labour or physical examination may 
 
 cause rupture. 
 
 Rupture into the peritoneal cavity is the most frequent ; 
 
 the results of this depend on the quantity and quality of 
 
 the fluid. In some cases, after rupture, the fluid may be 
 
 absorbed and the rent close again. The least dangerous 
 
 fluid is that in the unilocular cysts. In other cases the 
 
 contents are difficult of absorption, and may remain for 
 
 quite a time in the peritoneum without leading to changes. 
 
 If, however, the colloid matter be mixed with blood, pus, or 
 
 the contents of a dermoid, peritonitis is apt to be set up, 
 
 V 
 
HAIMORRHAGE IN THE CYSTS. 
 
 387 
 
 and this may prove fatal. If much fluid escapes, the 
 tumour diminishes in size and shape, and becomes flaccid 
 in part. After papillomatous cysts rupture, secondary 
 papillary developments generally take place in the peri- 
 toneum. Fluid is also increased in the latter — hydro-peri- 
 toneum. 
 
 When the fluid is gelatinous or colloid, small masses of it 
 often become attached to the peritoneum, which becomes 
 congested and roughened. This may lead to crepitus on 
 palpation. These have been wrongly described as myxoma 
 peritonei. They are really pseudo-myxomata. 
 
 Perforation into the intestines may occur, most frequently 
 into the rectum. This may lead to improvement in some 
 cases ; but, sometimes, infective inflammation or gangrene 
 may be set up. Rupture into the stomach or small intes- 
 tine is rare. 
 
 It may also take place through the bladder, vagina, 
 abdominal wall, or Fallopian tube. 
 
 Hsemorrhage in the cysts. — Sometimes this may be 
 due to rupture of a vessel in connection with the 
 increase in size of a cyst. It may occur after puncture. 
 In papillomatous cysts spontaneous haemorrhage may take 
 place. The most common cause is torsion of the pedicle. 
 Generally it is slow and gradual, but it may be sudden and 
 extensive. 
 
 Suppuration and gangrene. — These may follow puncture, 
 torsion of the pedicle, communication with the bowel. 
 After labour they may take place, an important factor in 
 their causation being the damage sustained to the cyst wall 
 by the pressure it has borne. 
 
 < i 
 
 I >. 
 
 i'-n 
 
 i 
 
 I 
 
 Symptoms Associated with Ovarian and Broad 
 Ligament Cysts. 
 
 tfl 
 
 By far the greater number develop slowly, producing no 
 symptoms until considerably advanced, the cysts reaching 
 
V 
 
 ^ 
 
 388 
 
 AFFECTIONS OF THE OVARIES. 
 
 above the umbilicus, it may be; often the patient only 
 discovers the mass accidentally. One of the commonest 
 early symptoms is vesical tenesmus, constipation, or pain 
 on defalcation. Sometimes pains in the pelvis or abdomen 
 are first noted. There may be nervous phenomena, e.g. 
 syncope. Generally the patient only begins to feel ill when 
 the stomach functions are altered. 
 
 Dyspeptic symptoms gradually develop, and nutrition 
 suffers. The patient loses strength. Abdominal pains 
 may develop from peritonitis. CEdema of the lower part 
 of the body may supervene, and death may occur from 
 exhaustion. 
 
 Sometimes symptoms may develop early, when the 
 tumour is small and in the pelvis ; such as pelvic pains 
 and difficulty of micturition and defaecation. These pass 
 away if the tumour rises out of the pelvis. Attacks of pain 
 are produced also when the tumour is small, as a result of 
 peritonitis or torsion. 
 
 It is best to consider the symptoms, as Olshausen does, 
 according to the following plan : — 
 
 Symptoms produced by ovarian disease per se. — These 
 mainly refer to menstruation. As a rule it is not much 
 interfered with. But all forms of disturbance are found 
 in the course of the disease. Dysmenorrhoea is very 
 rare. Early menorrhagia is somewhat frequent, and, 
 with metrorrhagia, is found especially in double broad 
 ligament cysts, probably due to interference with the pelvic 
 circulation. As a result of this loss of blood considerable 
 anaemia may follow. 
 
 Amenorrhoea is often found. If the patient's health be 
 good, this may be due to bilateral cysts of the ovaries, 
 malignant disease, pregnancy. But often it may be due to 
 a poor general condition of health. \ 
 
 Sterility may result from ovarian tumours, though preg- 
 nancy may take place with a large cyst or even with bi- 
 lateral ones. It is important to note that these tumours 
 
 I \ 
 
SYMPTOMS DUE TO TRESSURE OF THE CYSTS. 389 
 
 Fig. 116. — Outline show- 
 ing the gradual increase 
 in size of a splenic 
 tumour. 
 
 In extreme cases the 
 
 may cause certain signs of pregnancy, e.g. mammary areola, 
 
 enlargement and pains in the breasts, 
 
 secretion of colostrum. 
 
 Symptoms due to pressure of 
 
 t/ie cysts. — Small tumours impacted 
 
 in the pelvis cause pelvic pains, 
 
 difficulty in micturition and defae- 
 
 cation. These are aggravated if in- 
 flammation supervenes. 
 
 Large tumours growing into the 
 
 abdomen may also drag on the 
 
 bladder and cause tenesmus ; this 
 
 may also produce dragging pains. 
 
 Digestion is interfered with, as the 
 
 stomach and intestines are pressed 
 
 on, though alterations may not be 
 
 marked for a considerable time. 
 
 diaphragm is pressed upwards and breathing is interfered 
 
 with. The heart may also be dis- 
 placed upwards, and palpitation 
 produced. 
 
 The renal veins may be piessed 
 on, and albuminuria caused. The 
 ureters may be pressed on, leading 
 to their dilatation and to hydrone- 
 phrosis. This may lead to sup- 
 pression of urine. 
 
 In many cases of large cysts it 
 has been noted that small amounts 
 of concentrated urine are passed, 
 depositing mixed urates on standing. 
 Cystitis may be caused by ovarian 
 cysts, and when septic may lead to 
 
 kidney infection. In patients dying with large ovarian 
 
 tumours, or dying after ovariotomies, it has been remarked 
 
 that kidney disease is very often present. 
 
 Fig. 117. — Outline of a 
 liver greatly enlarged with 
 malignant disease. 
 
 «,i.if 1 
 
 I J 
 
390 
 
 AFFECTIONS OF THE OVARIES. 
 
 Haemorrhoids, varix, and oedema of the lower limbs, as 
 a result of pressure on abdominal veins, is not frequent. 
 Ascites is rare as a result of mere pressure. 
 
 The uterus may be pressed upon and somewhat dis- 
 placed. Sometimes it may be dragged upwards by the 
 traction of the cyst on the bladder. It may be made to 
 prolapse in some cases. Umbilical hernia may result. < 
 
 Symptoms due to complicating conditions. — Peritonitis 
 is common. In many cases no symptoms are produced 
 in the development of even marked adhesions. It may, 
 however, be associated with pains. 
 
 Sometimes, owing to pressure or to adhesions, the bowel 
 functions are disturbed, irritation and diarrhoea being 
 caused. 
 
 Haemorrhage into the cyst may cause no symptoms in 
 cases where it is slow and scanty. Sometimes it may pro- 
 duce acute anaemia, collapse, quick feeble pulse, and may 
 lead to death. 
 
 Suppuration or gangrene is associated with the usual 
 symptoms of septic infection. 
 
 Torsion of the pedicle produces symptoms which vary 
 according to acuteness of the attack. In a typical case, 
 suddenly produced, there is sharp abdominal pain and 
 shock \ if marked haemorrhage takes place in the cyst, 
 additional symptoms are present. 
 
 If the patient gets over the attack, she suffers from poor 
 health, peritonitis being present. 
 
 Slowly produced torsion may produce only symptoms 
 of chronic peritonitis. Sometimes, however, torsion may 
 exist with no inflammation, even though considerable 
 haemorrhage occur in the cyst. 
 
 Rupture of the cyst may be followed in some cases by no 
 symptoms when innocuous fluid escapes into the peritoneal 
 cavity. 
 
 When harmful fluids suddenly escape, there may be col- 
 lapse, shock, or symptoms of acute peritonitis. In other 
 
 '\ 
 
OVARIAN CYSTS. 
 
 39 i 
 
 cases, especially where rupture occurs slowly, pcritoiiitis may 
 only gradually be developed. Often, marked diuresis and 
 diaphoresis take place. 
 
 When rupture has taken place into the intestines, the 
 cyst contents are passed by the rec*^um, and violent diarrhoea 
 may be set up. When the bladder is opened into, tenesmus 
 and dysuria are marked. 
 
 Physical Signs in Ovarian and Broad Ligament 
 
 Cysts. 
 
 I. OVARIAN CYSTS. 
 
 {a) Entirely within the Pelvis. 
 
 I. Lateral to the Uterus. 
 
 Physical signs. — Bimanually, a rounded, firm mass is felt 
 at the side of the uterus, movable unless fixed by adhesions. 
 
 If very small, it may be at the 
 normal level of the ovary ; if larger, 
 on a lower plane, usually behind the 
 broad ligament, rarely in front of it. 
 These small cysts rarely feel elastic 
 or give fluctuation. 
 
 2. Behind the Uterus. 
 
 Physical signs. — Bimanually, a 
 
 rounded, firm mass is felt in the 
 
 pouch of .Douglas, pushing the 
 
 „ o ^ ,• r uterui to the front : if it be not 
 
 Fio. 1 18.— Outline of an ' 
 
 enlargement of the left mipacted nor adherent It may be 
 lobe of the liver, due to moved freely. Sometimes it may 
 malignant disease. f^^j ^^^^^ ^^^x^^ especially in the 
 
 case of dermoids. The connection of the pedicle with 
 the uterus may be made out, especially by rectal examina- 
 tion, or on pulling down the uterus with forceps. Some- 
 
39^ 
 
 AFFECTIONS OF THE OVARIES. 
 
 I. 
 
 2. 
 
 3- 
 
 4- 
 5- 
 
 times it is necessary to pass a sound to distinguish the 
 uterus clearly. 
 
 These small ovarian cystomata in the pelvis must be dis- 
 tinguished from — 
 
 Encysted peritonitic effusions. 
 
 Cellulitic deposits. 
 
 Haematocele and haematoma. . . 
 
 Broad ligament cysts. 
 
 Hydro-, haemato-, and pyosalpinx. 
 
 6. Ectopic gestation. 
 
 7. Fibroid and fibrocystic tumours of the uterus. 
 
 8. Retroversion of the gravid uterus. 
 
 9. Solid ovarian tumours. 
 
 (p) When the Cyst is Large and Abdominal. 
 
 On inspection, the abdomen is larger than normal. The 
 distension may be especially marked on one side, but it 
 
 is often uniform. The abdominal 
 veins are often dilated, and lineae 
 albicantes present. The measure- 
 ment from the anterior-superior iliac 
 spine to the umbilicus is usually 
 greater on the side to which the 
 tumour belongs. In very marked 
 cases the abdomen is pendulous 
 and smooth ; the lower ribs may 
 be curved outwards. 
 
 On palpation, the tumour may 
 be defined above and at the sides. 
 Fig. 119. -Outline of a except when very large, or the ab- 
 
 left renal ttimour, with , : , n . 1 • 1 ^ t^ 
 
 the descending colon in dommal wall too thick or tcnsc. ^ It 
 front of it. is felt to be more or less spherical, 
 
 but irregularities may develop as 
 secondary cysts become marked. The resistance is elastic 
 in parts, or over the whole tumour, and fluctuation may be 
 
 \ \ 
 
OVARIAN CYSTS. 
 
 393 
 
 k 
 
 obtained, except in cases where the cyst contains numerous 
 small cavities or thick fluid ; or where the abdominal walls 
 are thick. Sometimes, in a lax condition of the abdomen^ 
 the hand may be passed around a considerable part of the 
 tumour. On bimanual examination, the uterus can usually 
 be made out distinct from the tumour (unless adhesions 
 exist), separately movable, displaced and attached by means 
 of the pedicle at one corner. 
 
 The uterus is generally anterior to the cyst. It is often 
 elevated, and is usually on one or 
 other side of the middle line. It 
 may be elongated by traction. In 
 some cases it is not raised up. It 
 may be found retroverted, lateri- 
 verted, or prolapsed. Its mobility 
 is the more interfered with the 
 larger the cyst. 
 
 The vagina is elongated if the 
 uterus is dragged upwards. 
 
 Fluctuation may be often felt bi- 
 manually. It is important to note 
 that no variations in the consistence 
 of the cyst wall take place from time 
 to time. 
 
 On percussion, various signs are 
 obtained. If the patient be in the dorsal position, in the 
 case of a not too large cyst, there is dulness over the tumour, 
 and it is surrounded above and laterally by a resonant note 
 due to intestines ; the latter varies, ot course, according to 
 the presence of faeces in the bowel, and it may be altered, 
 especially, at the sides, by fluid in the peritoneal cavity. 
 
 On changing the position of the patient, the percussion 
 results are found to be the same, though there may be 
 variation if the tumour is not very large and very mov- 
 able. 
 
 In cases of the largest cysts, the intestines are so pushed 
 
 KiG. I20, — Outline of a 
 right renal tumour, with 
 the ascending colon in 
 front of it. 
 
 III 
 
V. 
 
 394 
 
 AFFECTIONS OF THE OVARIES. 
 
 I I 
 
 back that they only give a note in the loins. The trans- 
 verse colon and stomach do not 
 reach the abdominal wall. The 
 hepatic dulness disappears anteriorly 
 as far round as the axilla. The 
 diaphragm is pushed up, and may 
 reach as high as the second rib on 
 the right side. The lungs and heart 
 are markedly displaced upward. 
 Splenic dulness is lost. 
 
 On auscultation, no bruit is heard, 
 as in the case of a fibroid or a preg- 
 FiG. 121.— Outline show- nant uterus. Friction or creaking 
 
 ing a large hydrone- ^^ ^^^^^ ^^^^^ ^^^^^ ^^^ j. 
 
 phrosis of the left side, •' ^ 
 
 and the projection due tonitic thickenmgs, or when colloid 
 to a suppurating kidney matter escapcs from the cyst, or 
 on the right side. fj.^^^ ^^^ ^^^^ cavity to another. 
 
 When adhesions are present, there may be tenderness on 
 palpation, though often this is absent. Sometimes the cyst 
 may be felt to move only with the 
 abdominal wall, and not independent 
 of it. The intestines may be ad- 
 herent in front of it, giving a tym- 
 panitic note. In a large number 
 of cases it is impossible to diagnose 
 adhesions. 
 
 When rupture occurs, and a con- 
 siderable quantity of fluid escapes, 
 the tumour may have been found 
 to diminish in size, to change in 
 shape, and to show flaccidity. Free 
 fluid may sometimes be detected in 
 
 the peritoneal cavity. 
 
 T\ • jr i • 1 J - • jr patient lies on her back. 
 
 Differential diagnosis of 
 
 large ovariati cysts. —There are many abdominal and 
 
 pelvic swellings, which it may be difficult to distinguish 
 
 Fig. 122. — Outline show- 
 ing free ascitic fluid in 
 the abdomen when the 
 
 w 
 
BROAD LIGAMENT CYSTS. 
 
 395 
 
 from these large cysts. The most important are as 
 follows : — 
 
 Fluid in the peritoneal cavity free or encysted. 
 
 Fibroids and fibrocystic tumours of the uterus. 
 
 Distended bladder. 
 
 Obesity. 
 
 Phantom tumour. 
 
 6. Pregnancy ; hydramnios, 
 
 7. Hsematoma; haematocele. 
 Ectopic pregnancy. 
 Omental, mesenteric, and retroperitoneal tumour. 
 
 10. Renal, splenic, and hepatic enlargements. 
 
 11. Faecal accumulation. 
 
 12. Hydatid cysts. 
 
 I. 
 2. 
 
 3- 
 4. 
 
 5- 
 
 8. 
 9- 
 
 {c) When there is a Cyst in each Ovary. 
 
 This condition can only be exactly diagnosed when the 
 tumours are not too large, or not too close together ; also, 
 it is easier when they are unequal in size. 
 
 Where two large cysts are close together, the sulcus 
 between them may be mistaken for the depression between 
 two parts of the same cyst, and vice versa. 
 
 If the cysts are not very large and not adherent, inde- 
 pendent movements can be got in them. Sometimes they 
 may become firmly joined, and communication may open 
 between them. 
 
 II. BROAD LIGAMENT CYSTS. 
 
 Small ones may be felt bimanually. Large ones are 
 recognised as fixed in position (very rarely they may 
 become pedui^ulated). They are close to the uterus, 
 which is felt displaced in most cases upward, forward, 
 and to one side. The bladder and bowel may also be 
 displaced. The tumour may thus have a tympanitic note 
 
396 
 
 AFFECTIONS OF THE OVARIES. 
 
 I 
 
 over it. Per vaginam the cyst may be felt low in the 
 pelvis. 
 
 In the case of the i)arovarian cyst, the wall is felt to be 
 thill and flaccid, and fluctuation easily obtained. It is of 
 very slow growth usually. In some cases, owing to the 
 flaccidity of the cyst, it may be entirely missed when a 
 bimanual examination is made. 
 
 IJroad ligament cysts are us .illy less round and circum- 
 scribed than are ovarian. They arc not 
 elastic in feeling when small. 
 
 Sometimes, in the papillomatous cysts, 
 [| the papillary growths may be felt bi- 
 manually ; if perforation of the wall occurs, 
 \ these may be more readily recognised, 
 [i and the accomj)anying ascites made 
 \i out. 
 
 Ovarian Hvdrocki.k. 
 
 'I'lrs term has been given by IJland 
 
 l"'iG. 123. Ovarian Sutton to a sac containing thin fluid 
 
 hydrocele, due to found occasionally on the posterior layer 
 
 distension of ov.ir- ^f ^i^^ i^^oad ligament. The outer end 
 
 toneum Tlie 0^ the Fallopian tube, which is elongated 
 
 relations of tube and somewhat dilated usually, com- 
 
 and ovary are seen, municates with the sac. In small cysts 
 
 the ovary projects on the floor of the sac ; in large ones it 
 
 is spread out and blended with the sac wall, often being 
 
 unrecognisable as a distinct structure. 
 
 The condition is due to the distension of a fold of 
 peritoneum, whic^h occasionally surrounds the ovary — the 
 so-called "ovarian sac." This sac, in certain mammals, 
 exists normally as a covering to the ovary, i\^. hyrena, rat, 
 mouse, mare, guinea-pig. In others, e.g. porcupine, baboon, 
 the sac is only partly formed. Cases of ovarian hydrocele 
 are sometimes found in some of these mammals. 
 
 The hydrocele may empty itself from time to time through 
 
OVARIAN HYDROCELE. 
 
 397 
 
 the tube and uterus, 
 juirulent. 
 
 Sometimes the contents become 
 
 Solid Tumours of thf. Ovary, 
 
 Fibroma. — Fibroma of the ovary is rare. It may occur 
 on one or on both sides. It forms a hard, smooth, or 
 nodular mass, and may be found at one special part of the 
 ovary, or may obliterate the whole organ. 
 
 Fibromyoma. — This tumour is sometimes met with. It 
 may have the appearance of a uterine fibromyoma ; but 
 in some cases it is difificult to distinguish from a fibro- 
 sarcoma. 
 
 Sarcoma. — The spindle-cell form is more frequent than 
 the round-cell variety. It may occur in infancy or in adult 
 life. On microscopic examination various appearances are 
 found. Sometimes there may be a re.semblance to carcin- 
 oma ; possibly, as Bland Sutton suggests, in some cases the 
 entangling of the Graafian follicle in the sarcomatous tissue 
 may account for this appearance. 
 
 These tumours grow rapidly, and may produce metastases, 
 especially in the peritoneum, intestines, stomach, and pleura. 
 Ascites usually develops. Cystic changes may occur in the 
 tumour as a result of fatty degeneration, mucoid change, 
 or haemorrhage. 
 
 The tumours are rounded masses, with a fairly regular 
 surface, or they may be nodular. They may occur bi- 
 laterally. Adhesions are often present. 
 
 Carcinoma. — This neoplasm may occur primarily or 
 secondarily in the ovary. The scirrhous, encephaloid, colloid, 
 and papillary varieties may be met with. 
 
 Primary cancer is especially apt to occur along with 
 ovarian papillomatous cysts ; also with ordinary cysts and 
 dermoids. It may be bilateral. It grows rapidly and tends 
 to produce ascites ; secondary deposits are most frequent 
 in the retroperitoneal glands, peritoneum, stomach, intes- 
 tines, and liver. 
 
 '^ 
 
 * 
 
 •l^ 
 
 n 
 
 '% 
 
 
 
 
 
 w 
 
 
 fffi 
 
 "V|BEi 
 
 1H 
 
 . 
 
 Hi 
 
 
 ^H 
 
 
 ■S 
 
 - j 
 
 \ ^^1 
 
398 
 
 AFFECTIONS OF THE OVARIES. 
 
 Secondary cancer of the ovary may follow the disease in 
 other parts, e.g. uterus, mammae, pylorus. 
 
 Papilloma of the ovary. — Occasionally the ovary may 
 present papillomatous growths from the surface, exactly 
 resembling those found in papillomatous cysts. They may 
 be found without any cystic changes in the ovary. Williams 
 believes that they are always derived from the germinal 
 epithelium. They may extend to surrounding peritoneum, 
 and small portions may be implanted. 
 
 Tuberculosis of the ovary. — This is not so frequent as 
 in the case of the tubes and uterus. It usually occurs 
 along with tuberculosis of the tubes or uterus, or both, 
 
 with tubercular peritonitis. 
 Sometimes, in phthisical wo- 
 men, the ovaries may be the 
 only part of the genital tract 
 affected. It is met with in the 
 miliary form, in caseating 
 masses, along with abscess for- 
 mation. 
 
 Tuberculosis may attack 
 ovarian cysts. 
 
 Coexistence of pregnancy 
 and ovarian tumours. — Pregnancy may be found along 
 with all varieties of ovarian tumour, unilateral or bilateral. 
 Spiegelberg and Olshausen think that they often grow rapidly 
 during pregnancy. The tumour may lie in the pelvis or in 
 the abdomen. If in the pelvis, it usually lies in the pouch 
 of Douglas ; in the abdomen, it generally lies lateral to the 
 uterus and somewhat in front. The earlier the gestation 
 and the smaller the tumour, the more easily can the uterus 
 and tumour be distinguished by palpation. 
 
 In advanced pregnancy this is generally impossible. Some- 
 times the abdomen may be enormously distended in advanced 
 pregnancy ; or where pregnancy occurs with a large tumour, 
 the tension of the wall may be great. 
 
 Fig. 124. — Superficial papilloma 
 of ovary. 
 
TUBERCULOSIS OF THE OVARY. 
 
 399 
 
 ick 
 
 icy 
 
 )ng 
 
 ral. 
 
 ily 
 
 in 
 
 [ch 
 
 he 
 
 ke- 
 
 The patient is apt to suffer more than in ordinary preg- 
 nancy, e.g. from varicose veins, oedema of legs. Abortion 
 is apt to occur in certain cases. Labour may be seriously 
 interfered with. 
 
 After emptying the uterus, torsion, rupture, or suppuration 
 may sometimes occur. 
 
 Treatment. — The only available treatment for tumours 
 of the ovary is removal. This is to be carried out as 
 follows : — 
 
 Hydrops foUiculorum. — If this condition require opera- 
 tive treatment, either puncture and destruction of the small 
 distended follicles may be carried out, or removal of the 
 whole ovary, by means either of anterior colpotomy or 
 abdominal section. The procedure is the same as in a 
 salpingo-ocjphorectomy. 
 
 Proliferating ovarian cyst. — The operation for the re- 
 moval of an ovarian tumour has long been known by the 
 name of ovariotomy. 
 
 The nature of the procedure and the difficulty of mani- 
 pulation vary according to the size and condition of the 
 tumour, adhesions, condition of the patient's health, etc. 
 For many years an abdominal incision has been employed 
 for all varieties of cyst. Recently, Martin and others have 
 advocated the advantage of anterior colpotomy for certain 
 cases. 
 
 Small cysts not larger than two fists. — These may be 
 removed by abdominal section, or by anterior colpotomy. 
 If there are many adhesions which can be diagnosed, the 
 former of these methods alone should be employed. 
 
 When the incision is made into the peritoneal cavity, the 
 cyst, if very small, is removed along with the corresponding 
 tube, just as in the case of a salpingo-oophorectomy, pre- 
 liminary evacuation of the cyst not being necessary. 
 
 Where the cyst is too large to remove in this wa , it is 
 aspirated before the pedicle is secured. 
 
 Large ovarian cysts. — These should only be removed by 
 
 ^ ! 
 
V 
 
 400 
 
 AFFECTIONS OF THE OVARIES. 
 
 i ! 
 
 abdominal section. The abdomen is opened, as already 
 described. The incision, to begin with, should be long 
 enough to admit the hand. 
 
 In most cases the whitish surface of the cyst is seen next 
 the abdominal wall. Its relation to the breathing should be 
 watched for a moment. If it moves freely with respiration, 
 no extensive adhesions to the parietes are present. The 
 fingers of one hand are then introduced and carried all over 
 the tumour to make out its relations and the presence of 
 adhesions. 
 
 If only a few parietal adhesions exist, they are broken 
 with the fingers. If extensive, they are attended to after 
 
 Fig. 125. — Trocar. 
 
 evacuation of the sac. Omental and intestinal adhesions 
 are also left until after this is carried out. 
 
 Evacuation of cyst. — In order to reduce the size of the 
 tumour, the cystic contents must be removed (save when 
 they are purulent or gangrenous ; in such cases the tumour 
 should be removed en masse). 
 
 Before puncture an assistant should steadily compress the 
 patient's flanks with the palms of his hands, and should con- 
 tinue in this position as long as fluid flows from the tumour. 
 
 The largest cyst near the abdominal incision is chosen 
 for puncture. Various trocars are used. The simplest 
 method is i\. pierce the cyst wall with a bistoury. As the 
 assistant presses in the flanks, a thin stream of fluid (except 
 when it is thick) flows steadily out as a jet, and is caught in 
 sterilised basins. 
 
TREATMENT OF ADHESIONS. 
 
 401 
 
 If the bistoury be not used, puncture may be made with a 
 simple trocar and cannula, attached to a rubber tube. The 
 latter hangs over the edge of the table and drains the cyst 
 by syphon action. Large complicated trocars are not neces- 
 sary ; they are difficult to keep clean. 
 
 If the puncture of one cyst is not sufficient to reduce the 
 size of the tumour, so that it can be removed, other cysts 
 should be opened from the interior of the one already 
 punctured. This may be done with a finger, knife, scissors, 
 or trocar. 
 
 In some cases, on account of the colloid nature of the 
 fluid or the presence of fibrinous < .ots, nothing escapes in 
 the tube. This happens also when the tumour walls rupture 
 owing to their brittleness, or because the cyst is so numer- 
 ously subdivided. In these conditions either the cyst should 
 be removed en bloc^ through a large abdominal incision, or, 
 if too large for this, it should be opened so that the hand 
 can be introduced to remove the contents and to break 
 down the septa. 
 
 If the cyst contents are gangrenous or purulent, the tumour 
 should be removed en masse. If, only after an opening has 
 been made, the dangerous character of the contents has been 
 found out, the opening should be closed with forceps and 
 the tumour removed from the abdomen through an enlarged 
 incision. 
 
 Usually only slight haemorrhage results from the breaking 
 down of the cyst interior. Sometimes, however, marked 
 bleeding occurs. When this happens the pedicle should 
 be temporarily constricted with forceps until the cyst is 
 removed from the cavity, and the ligatures are ready to 
 be applied. 
 
 Treatment of adhesions. — After the evacuation 0/ the cyst 
 contents, the edges of the opening are grasped in strong 
 forceps and the tumour is drawn outwards in order that 
 adhesions may be severed. Parietal adhesions may be 
 broken through with the finger tips; when they are 
 26 
 
 \S.\ 
 
 ■A 
 
4oa 
 
 AFFECTIONS OF THE OVARIES. 
 
 very tough and tendinous, they may require to be cut 
 
 through. 
 
 When there is a circumscribed patch of dense adhesion, 
 
 the corresponding part of the cyst wall may require to be 
 
 cut from the rest of the sac ; 
 in such a case, the lining 
 secreting portion should be 
 entirely dissected off. 
 
 When oozing takes place 
 from torn adhesions it may 
 be checked by pressure of a 
 hot sponge. Any points that 
 bleed particularly freely may 
 be tied or burned with a 
 cautery. It may be necessary 
 to pass the catgut through 
 the tissue by means of a 
 needle. 
 
 Parietal adhesions over the 
 front of the tumour may 
 make it difficult to know 
 where the peritoneum is, 
 during the opening of the 
 abdomen. In attempting to 
 strip off adhesions one may 
 at the same time remove the 
 parietal peritoneum. After 
 evacuating the cyst the dis- 
 tinction can usually be made. 
 
 Fig. 126 -N^laton's forceps, used ^^^ separation of the 
 
 in drawing out the cyst. . ^ . 
 
 adhesions carried out. 
 
 Omental adhesions are next in frequency after parietal 
 
 adhesions. Usually the omentum lies above the umbilicus. 
 
 If it should lie in front of the tumour below the umbilicus, 
 
 so as to interfere with the opening into the cyst, the incision 
 
 should be prolonged downwards in order that the omentum 
 
 \'\ 
 
TREATMENT OF ADHESIONS. 
 
 403 
 
 |e 
 
 may not be wounded. Sometimes, however, it reaches to 
 the symphysis. 
 
 It should be separated from the parietes, and an endeavour 
 should be made to get to one side of it in order to puncture 
 the cyst. If a piece of the omentum which is in the way 
 can be conveniently ligatured and divided, this may be done. 
 If there is no other method, it may be necessary to puncture 
 the omentum in order to enter the cyst. 
 
 In drawing out the tumour the omental adhesions are 
 gradually torn through. This is best brought about by 
 rubbing them off with a dry sponge or gauze pad. Firm 
 bands may require to be torn through with a pair of forceps 
 or with the fingers. Bleeding vessels in the omentum may 
 be ligatured with catgut, but if, when the omentum is 
 freed, any extensive oozing surface should remain, strong 
 catgut (No. 3) ligatures should be tied around it, and the 
 oozing part cut away. 
 
 Adhesions to mesentery and intestine are not very 
 common. They are usually found on the back and sides 
 of the cyst. If the adhesions are short, they should be 
 torn through by being rubbed off the cyst with a sponge, 
 or cut with a knife. If they are long, the bands may be 
 ligatured and cut. If the adhesions are very firm and short, 
 it may be necessary to dissect a portion of the outer wall of 
 the cyst to which they are attached, leaving it m continuity 
 with the bowel or mesentery, care being taken that no part 
 of the inner secreting surface is left. 
 
 When intestine is adherent to the pedicle it may not be 
 easily recognised. Or, when the pedicle is very broad and 
 there are no adhesions, the operator may think that the 
 bowel is adherent. When any extent of peritoneum has 
 been torn from the bowel, the rawed surface should be 
 covered with neighbouring peritoneum by means of fine 
 catgut (No. o) and small needles. 
 
 Mesenteric adhesions should b. separated and then liga- 
 tured, or vice versa. 
 
AFFECTIONS OF THE OVARIES, 
 
 If the vermiform appendix be adherent, the adhesions 
 should be torn through. If this be very difficult, it may be 
 necessary to remove it. 
 
 Splenic and hepatic adhesions must be divided with the 
 greatest care. v 
 
 Uterine adhesions are mostly found in cysts which lie in 
 the pouch of Douglas and are adherent to it. 
 
 Bladder adhesions must be carefully dealt with. Some- 
 times the attached bladder may be mistaken for part of the 
 cyst, and there is danger of cutting into it or removing it. 
 This mistake is most apt to occur when the bladder is 
 markedly displaced upwards. When the adhesions are 
 divided, bleeding points should be ligatured. 
 
 Adhesions to the pelvic floor may be difficult to separ- 
 ate. Sometimes it is quite impossible. There is danger ^ 
 of tearing into a large vessel, the ureter, the bowel, or ^ 
 the vagina. Bleeding points on the tumour may be held 
 with forceps or with ligatures, until the pedicle is tied. 
 
 Treatment of the pedicle. — The pedicle consists of the 
 tube, broad, ovarian, and infundibulo-pelvic ligaments. It 
 varies greatly in length and width in different cases. 
 
 In cases of torsion it may be very brittle, the vessels being 
 closed by thrombi. Sometimes the pedicle is double as a 
 result of atrophy of a mesial portion. 
 
 Sometimes the appendages of the opposite side may be 
 adherent to the cyst, thus making it difficult at first to say 
 to which side the tumour belongs. Intestines may become 
 adherent to the pedicle, and should be separated. 
 
 Sometimes no pedicle is found in cases where torsion 
 has occurred, the original pedicle having been thereby 
 divided. Ine tumour thereafter thrives by means of the 
 adhesions which have formed. If the tumour has developed 
 between the layers of the broad ligament, or if it has 
 grown behind the ligament and become attached to it, no 
 pedicle exists. The treatment of these conditions will be 
 considered later {^ide p. 406). 
 
 X\ 
 
TREATMENT OF ADHESIONS. 
 
 405 
 
 The pedicle is secured by means of ligatures. To pass 
 them, the cyst should be drawn outside the abdominal in- 
 cision and held by an assistant. • ■ 
 
 If very large, the mass of it may be cut away, large forceps 
 securing the basal portion. This facilitates the application 
 of the ligatures. " 
 
 Strong chromic or juniper catgut (No. 4) or twisted silk 
 ligatures may be used. They are passed with the special 
 pedicle needle, care being taken not to pierce a vessel. If 
 the pedicle be small, the Staffordshire knot may be used. 
 If it be large, or if it be short, two interlacing ligatures may 
 be used. 
 
 If it be very broad, three or more interlacing ligatures 
 may be necessary. These have been described on p. 267. 
 The pedicle is next grasped on each side with forceps, and 
 the tumour cut away outside them. The stump is then 
 carefully sponged. If there be any bleeding from it, the 
 ends of a ligature are passed around the pedicle and tied 
 firmly. The ligature ends are next cut short and the 
 forceps are removed. 
 
 Ovarian cysts which have developed within the broad 
 ligament. — These are mainly papillomatous. Sometimes 
 this extraperitoneal development may be slight. In such a 
 case, after the evacuation of the contents of the cyst, the 
 pedicle may be secured by a series of interlacing ligatures 
 passed under the cyst from the uterus to the infundibulo- 
 pelvic ligament. In a more marked case, after evacuation 
 of the intraperitoneal portion of the cyst, the peritoneum 
 covering the extraperitoneal part is divided around its 
 attachment, and the tumour is enucleated. 
 
 In the most marked cases, the whole tumour lies under 
 the peritoneum. As it grows it may come into relation 
 with various structures of the pelvis, e.g. rectum, bladder, 
 uterus, etc., and marked displacement of these may occur 
 as well as firm adhesion to them. 
 
 In these cases, before enucleation is attempted, the 
 
 I 
 
 Vk 
 
V 
 
 406 
 
 AFFECTIONS OF THE OVARIES. 
 
 ovarian vessels should be controlled in the infundibulo- 
 pelvic ligament by means of a strong catgut suture passed 
 with a needle. After evacuation of the cyst contents, its 
 walls are pulled outwards by means of forceps, and its 
 peritoneal covering is incised on the upper surface if the 
 tumour be a pelvic one. If the cyst extend above the 
 pelvis the peritoneum is cut around the swelling near its 
 base. The tumour is then rapidly enucleated by means 
 of the fingers ; in some cases, by knife or scissors. Where 
 there is firm attachment to a delicate structure — e.g. bowel 
 — it may be necessary to leave behind a bit of the outer 
 portion of the cyst wall. None of the lining membrane 
 should be left. It should be pulled or scraped away. Care 
 must be taken not to injure the ureter or any large vessel. 
 The ureter is white in colour; it may be distended some- 
 what in these cases. 
 
 There may be a good deal of bleeding as enucleation 
 proceeds, but the preliminary ligature of the ovarian vessels 
 tends to diminish this. The inner part of the tube and 
 broad ligament may be ligatured close to the uterus at an 
 early stage with advantage. The ureters must not be caught. 
 
 As vessels are torn through they must be caught with 
 forceps and tied. Sometimes ligatures cannot be passed. 
 The galvano-cautery may be used, or the pressure of a hot 
 swab. 
 
 When the tumour is entirely removed, the peritoneal sac 
 should be closed by continuous catgut suture. It then lies 
 in a crumpled mass at the side of the uterus. 
 
 Sometimes when the uterus is too firmly attached to the 
 tumour, its removal may be necessary. 
 
 When the cyst develops in the folds of the mesentery, 
 its separation may be accompanied with much bleeding. 
 Ligatures must be carefully used, because too wide portions 
 must not be constricted lest the nutrition of the gut should 
 be interfered with. 
 
 When the cyst grows up behind the peritoneum in the 
 
SOLID OVARIAN TUMOURS. 
 
 m 
 
 front of the pelvis and abdomen, the abdominal incision 
 may not enter the peritoneal cavity at all. Usually, how- 
 ever, in such a case, it is opened into before the cyst can 
 be entirely enucleated. If the cyst can be removed, the 
 remaining cavity should be stuffed with gauze and allowed 
 to close gradually, being shut off from the peritoneal cavity. 
 
 Double extraperitoneal cysts. — These may be treated 
 by a double procedure similar to that just described. 
 Sometimes it is impossible to separate the uterus from the 
 cysts, and its removal, along with that of the tumours, is 
 necessary. 
 
 Incomplete operations. — Both in the case of extra- 
 peritoneal and of intraperitoneal cysts which become very 
 adherent to the pouch of Douglas, it mi,y be impossible to 
 remove the entire tumour. 
 
 In such cases, the inner lining — the secreting surface — 
 should be torn or scraped off, oozing of blood from the rest 
 of the wall being checked as much as possible. 
 
 If the remnant be a small one, it may be left in situ. If 
 it be large, its edges should be stitched to thvj edge of the 
 lower part of the abdominal incision, the cavity being 
 drained with iodoform gauze, and allowed to close 
 gradually. 
 
 In the case of the extraperitoneal cyst, an opening may 
 be made into the vagina, drainage being carried out by 
 means of a T-shaped rubber tube and by iodoform gauze. 
 In such a case, the first incision into the sac is carefully 
 closed before the abdominal wound is stitched. 
 
 Dermoid cysts of the ovary. — These should be removed 
 en masse. Evacuation should not lie attempted because of 
 the risk of escape of its contents into the peritoneal cavity. 
 The pedicle is secured just as in the case of simple cysts. 
 
 Solid ovarian tumours. — When these can be removed, 
 whether simple or malignant, the procedure is the same as 
 in the case of an ovarian cyst, save as regards the reduction 
 of the size of the tumour^ 
 
 v«. 
 
 % 
 
 \' 
 
 m 
 
V, 
 
 4o8 
 
 AFFECTIONS OF THE OVARIES. 
 
 / 
 
 Removal of a malignant growth need not be attempted 
 when the diseased ovary is adherent to surrounding parts 
 and infiltrating them, or when growths exist elsewhere. 
 
 Ovarian cyst complicating pregnancy. — In such a case 
 the cyst should be removed by abdominal section, save when 
 it is very small. The procedure is the same as in the non- 
 pregnant state. Care should be taken to disturb the uterus 
 as little as possible, not to puncture it, and not to mistake 
 it for a cyst. 
 
 After the operation, the patient must be kept under the 
 influence of morphine. 
 
 Adhesive plaster should be worn over the wound through- 
 out pregnancy, as well as a carefully adjusted belt. 
 
 Parovarian and other circumscribed broad ligament 
 tumours. — These are removed by abdominal section in the 
 manner in which extraperitoneal ovarian tumours are taken 
 away. 
 
 Minor Condittons in the Ovary. 
 
 The corpus luteum is liable to form a small cyst ; it may 
 become a small, hard, fibrous body, sometimes peduncu- 
 lated, or may calcify. Sometimes excessive haemorrhage 
 may occur in a follicle after its rupture. This may extend 
 beyond the follicle and distend the stroma. The ovary 
 may enlarge to the size of an egg or an orange. Hard 
 concretions are sometimes found in the ovary, probably 
 formed of old coagulated proteids derived from blood clot. 
 
 ! \ 
 
CHAPTER XIV. 
 
 AFFECTIONS OF THE UTERUS. 
 
 Malformations, 
 
 V 
 
 Complete absence of the uterus. — This is a very rare con- 
 dition. The bladder and rectum touch. The tubes are 
 absent, rudimentary, or represented by solid rods. The 
 ovaries are absent, rudimentary, or of normal size. Com- 
 plete absence of uterus, tubes, and ovaries have mostly been 
 
 Fig. 127. — Rudimentary utenis. 
 It is seen as a small projection 
 on the bladder. 
 
 Fig. 128. — Uterus unicornis. 
 
 described in monstrosities. Sometimes signs of herma- 
 phroditism exist. 
 
 Rudimentary uterus. — This is found in various condi- 
 tions. It may be a mere thickening on the posterior 
 bladder wall, or a band continuous with the Fallopian 
 tubes and round ligaments. Sometimes there is a distinct 
 
410 
 
 AFFECTIONS OF THE UTERUS. 
 
 ff 
 
 Fig. 129. — Uterus unicornis, with right 
 rudimentary cornu attached. 
 
 median lump ending in the vagina ; in some cases this may 
 resemble a cervix. The uterus may sometimes be repre- 
 sented by two vertical ridges. The vagina may be absent 
 
 or small ; the outer 
 genitals may be nor- 
 mal, small, or mal- 
 developed. 
 
 Uterus biparti- 
 tus. — The cervix 
 may be well 
 developed and 
 connected with dis- 
 tinct cornua, solid or hollow. The ovaries may be normal, 
 absent, or atrophied. The vagina is often malformed. 
 
 Uterus unicornis. — In this form, only one cornu is 
 developed; it is directed from the cervix upwards and 
 towards one side. The other cornu is absent or rudi- 
 mentary. The rudimentary horn 
 may be a mere solid b::ixd. Some- 
 times it may be hollow for a short 
 distance or be perforated in its 
 whole length. The ovary and tube 
 may be normal, absent, or atro- 
 phied. 
 
 To distinguish between tube and 
 horn the insertion of the round liga- 
 ments should be noted. 
 
 Uterus didelphys. — This condition is rare. In it the 
 two common halves of the entire uterus remain distinct, 
 the cervical portions being close together. The vagina is 
 absent, single, or double. 
 
 Uterus bicomis. — In this condition the uterus is more 
 or less divided into two parts, by means of an external 
 depression. The separation rarely extends through the 
 cervix, though the latter may often, in these cases, be 
 divided by an internal vc Ucal septum. There is found 
 
 Fig. 130. — Uterus didel- 
 phys. 
 
 \ 
 
 i y 
 
IMPERFECT DEVELOPMENT. 
 
 411 
 
 quite a range of variation in shape, from a mere depres- 
 
 FiG. 131. — Uterus bicornis bicollis. 
 
 sion at the fundus to a deep division extending into the 
 cervix. 
 
 Uterus septus. — Here the uterus has the normal external 
 
 Fig. 132. — Uterus bicornis unicollis. 
 
 appearance, but inwardly a median septum, which may 
 reach from the fundus to the os externum, or not so far 
 down. 
 
 Imperfect Development of the Uterus. 
 
 Uterus infantilis. — In this condition the uterus has the 
 foetal characteristic, namely, shortness of the body relative 
 to that of the cervix ; the latter may be two or three times 
 the size of the former. 
 
 Atrophied uterus. — This is a condition of uterus some- 
 
412 
 
 AFFECTIONS OF THE UTERUS. 
 
 ^ 
 
 Fig. 133. — Uterus bicornis. The 
 upper part of the body 
 divided. 
 
 IS 
 
 times found in the adult, in which the organ has the adult 
 shape, but is undersized. 
 
 The causes of these latter conditions are not very evi- 
 dent. There is in some cases 
 f-— \ a fault of development. 
 
 \v^ Local pelvic inflammatory 
 ^^ changes may sometimes be a 
 factor. In dwarfs and cretins 
 the imperfect development is 
 often found. In early tuber- 
 culosis also, in chlorosis and 
 low health from other impor- 
 tant causes, certain conditions 
 of the nervous system, e.g. hysteria, epilepsy, are said to be 
 causes. 
 
 Diagnosis. — When the uterus is absent, there is, of course, 
 no menstruation. The female may undergo all the other 
 changes which take place at puberty, e.g. hair and breasts 
 may develop. In a rudimentary con- 
 dition of uterus there is no menstrua- 
 tion. Vicarious menstruation has 
 sometimes been reported in these 
 cases. They may develop at puberty 
 like other women, save as regards 
 menstruation. 
 
 The vagina is often rudimentary. 
 On examining the pelvis in these cases, 
 it is good to pass a sound into the 
 bladder ; the rectal finger feels it readily 
 when the uterus is absent or rudi- 
 mentary. It is important to make an 
 abdomino-rectal examination under anaesthesia. When the 
 unicornuate uterus exists, the well-developed horn may per- 
 form all the functions of the normal uterus. If the rudi- 
 mentary horn be pervious for a distance, accumulation of 
 menstrual blood may take place in it, though sometimes 
 
 Fig. 134. — Septate 
 uterus in which one 
 half is more de- 
 veloped than the 
 other. 
 
 
DIAGNOSIS. 
 
 413 
 
 no menstruation takes place on the malformed side in such 
 a case. It has occasionally happened that no menstruation 
 takes place from the developed horn, blood accumulation 
 occurring in the other (P. Miiller). 
 
 The distended horn is felt as an elastic or firm mass, often 
 sensitive to examination. It may be very adherent to 
 surrounding structures. It is important to remember that 
 a pregnancy may also take place in it, leading to a very 
 serious condition. 
 
 In the case of uterus didelphys, there are no symptoms 
 unless the vagina be absent or atresic, or one horn be closed. 
 On physical examination, two separate cervices or separate 
 cervical openings are felt. A sound 
 may be passed into each horn, and 
 the condition determined by abdomino- 
 rectal exploration. In uterus bicornis 
 there are no distinguishing symptoms ; 
 menstruation is often normal, but may 
 be irregular. When one horn becomes 
 pregnant, the other usually stops men- 
 struating, though in some cases it may 
 continue. On bimanual examination, jr,(. j-_ggpj^tgmgrug 
 especially under an anaesthetic, the 
 distinction between the horns can be made out. Atresia 
 of one horn may occur, leading to an accumulation of blood 
 above it. 
 
 The sac gradually pushes the open horn towards the 
 opposite side of the pelvis, and forces down the dilated 
 cervix and vaginal vault. Bimanually the mass is felt 
 elastic or firm. The unclosed os is crescentic, and is 
 stretched over the lower end of the tumour, when the 
 atresia is cervical ; it is felt at one side of the fornix, and 
 a sound may be passed into it. 
 
 P. Miiller points out that there is no record of a preg- 
 nancy in the closed horn in such a case, though it may 
 occur in the rudimentary horn of a unicornuate uterus. 
 
 II: 
 
 J! 
 
414 
 
 AFFECTIONS OF THE UTERUS. 
 
 Sometimes a vaginal septum of greater or less extent may 
 exist with the bicornuate uterus, and may cause a suspicion 
 of the latter condition. ' ^ ' ' 
 
 Uterus septus is usually recognised only when the 
 examining finger feels the septum in the cervix. When the 
 septum does not extend down so far, the condition may 
 never be found out. 
 
 Menstruation proceeds as normally. Blackwood reports 
 an interesting case where the flow took place, month by 
 month, alternately from one side and the other. 
 
 Atresia of one-half may occur, followed by distension 
 with blood. 
 
 When a complete septum exists, sounds passed into both 
 halves do not touch. 
 
 In the infantile and atrophied uterus, there is generally 
 no menstruation. This may continue throughout life with 
 no other signs or symptoms. Often, however, there are 
 periodic pains in the pelvis, with a flow of mucus from the 
 genitals. Periodic disturbances of other organs have been 
 noted in some cases, e.g. stomach disorder, palpitation, 
 pains in breasts, head, etc. Vicarious bleedings have been 
 described, though rarely. Neurotic disturbances are apt to 
 develop in these cases. Sometimes there may be a very 
 scanty or irregular menstruation in these cases. Sterility 
 generally marks the condition, but pregnancy may occur. 
 
 Bimanually the smallness of the uterus may be made out, 
 especially if the sound be passed into its lumen at the same 
 time. 
 
 When in any of these conditions there is accumulation 
 of menstrual blood on one side, pains occur on that side, 
 and in many cases continue for longer and longer periods 
 after the menstrual flow, until it may become more or less 
 continuous. The mass may cause pressure effects. Peri- 
 tonitis often takes place outside it. It may rupture into 
 the abdomen, vagina, the neighbouring horn, the bladder, 
 or the bowel. Suppuration may occur in it. 
 
 I \ 
 
TREATMENT, 
 
 415 
 
 Differential diagnosis. — The unicomuate uterus must be 
 distinguished from the infantile, atrophied, and rudimentary 
 uterus. The rudimentary cornu may be mistaken for a 
 small fibroid ; when distended, it may be mistaken for a 
 tubal, ovarian, or broad ligament swelling. A bicornuate 
 uterus, with one horn closed and distended, may be 
 diagnosed as a normal uterus associated with a fibroid, 
 ectopic pregnancy, or some other pelvic swelling. This 
 may be the case with a septate uterus, or with the uterus 
 didelphys. 
 
 Treatment. — In the unicomuate uterus with a rudimentary 
 horn, treatment is necessary, when accumulation of blood 
 occurs in the latter. If this takes place slowly, and causes 
 no serious disturbance, the case may simply be watched. 
 
 If rapid accumulation occurs threatening rupture, or if 
 peritonitis develops, operation is necessary. Abdominal 
 section should be performed, and the mass removed. If it 
 cannot be taken away, it should be emptied and stitched 
 into the edges of the abdominal incision. If pregnancy 
 takes place in this horn, removal is also necessary. It may 
 also be justifiable always to remove the opposite ovary at 
 the same time. In the bicornuate uterus, when disten- 
 sion of one -half occurs above an atresic portion, the 
 collection must be opened per vaginam. If, however, the 
 Fallopian tube on the same side is much distended, it is 
 probably best to perform an abdominal section first of all, 
 and either to remove both distended tube and cornu, or 
 to remove th' tubal portion, and, at a later date, to open 
 the cornu from the vagina. 
 
 In a septate uterus, where distensijn of an atresic half 
 has occurred, an opening must be made by way of the 
 cervix. If the corresponding tube is much distended, a 
 preliminary abdominal section for its removal must be 
 carried out. 
 
 In cases of deficient development of the uterus, good 
 feeding and tonics may sometimes do good. 
 
416 
 
 AFFECTIONS OF THE UTERUS, 
 
 % 
 
 Fig. 136. — Atresia of the 
 cervix. The uterus is 
 completely distended with 
 blood. 
 
 Atresia of the cervix. — This may be due to acquired 
 
 causes {vide p. 436). It may also be congenital. It may 
 
 be found in the single uterus, 
 when the whole cervix may b^ 
 atresic, or when there may be 
 a septum at the os externum 
 or OS internum. Mucus may 
 collect in the uterus before 
 puberty, but generally the con- 
 dition is only made out after 
 menstruation begins, owing to 
 the accumulation of menstrual 
 blood. (For the results of ac- 
 cumulation, vide " Atresia of the 
 Vagina"). 
 Atresia may also affect one or both horns of a bicomuate 
 
 uterus, or a unicornuate uterus. I 
 
 have already referred to its occur- 
 rence with a rudimentary horn. 
 Treatment. — Vide "Atresia of the 
 
 Vagina." 
 Abnormal commiinications of tlie 
 
 uterus. — There may sometimes be 
 
 found an opening into the rectum or 
 
 bladder, or into both. Vaginal atresia 
 
 may be present. Impregnation has 
 
 taken place either by way of the 
 
 rectum or urethra. These conditions are remains of the 
 
 cloacal state. 
 
 Doran has reported a bipartite uterus opening on 
 
 one side to the outer surface of the body. The uterus 
 
 may also sometimes communicate with the ascending 
 
 colon. 
 
 \ 
 
 Fig. 137. — Uterus in- 
 cudiformis. The bi- 
 cornuate uterus has 
 the shape of an anvil. 
 
INFLAMMATION, 
 
 417 
 
 Minor Malformations. 
 
 The uterus may sometimes be obliquely shaped, owing to 
 the imperfect development of the organ. The condition 
 might be mistaken for a unicornuate uterus. 
 
 Sometimes the uterine fundus is straight, giving the name 
 of anvil-shaped {uterus inctidiformis or biangularis) to the 
 organ. 
 
 Sometimes the vaginal portion of the cervix may be 
 small or rudimentary {itterus parvkollis or acollis). 
 
 The uterus biforis is the condition in which a median 
 partition divides the os externum into two parts (as in the 
 ant-eater). 
 
 Abnormal folding of the cervix. — Sometimes a flaplike 
 circular projection may be found inside the cervix (like that 
 normally found in the sheep), forming a second os externum. 
 It may be mistaken for a polypus, and may give rise to 
 haemorrhage. It may obstruct labour, and should be 
 removed when recognised. 
 
 Premature development of the uterus. — The uterus may 
 develop in early life into the adult form, with or without 
 accompanying changes in the rest of the genital tract, and 
 with one or more of the general changes met with at 
 puberty, associated with the development of secondary 
 sexual characters. 
 
 e 
 
 Inflammation of the Uterus. 
 
 The uterus is the commonest seat of inflammation in 
 women, especially in those who have borne children. This 
 is to be associated with the marked disturbances to which 
 the organ is subjected in relation to labour, and to its free 
 communication with the exterior, whereby microbial infec- 
 tion is made easy. It is impossible to give to traumatism 
 and other physical factors and to germ activity their proper 
 proportional values as factors in the causation of inflamma- 
 27 
 
418 
 
 AFFECTIONS OF THE UTERUS. 
 
 tion in the uterus. There can be Uttle doubt, however, that 
 in the majority of instances, the great cause is micro-organ- 
 ismal infection, entrance being gained through an injured or 
 rawed surface, 'i'he divisions under which this subject is 
 considered are arranged on the basis of the predominant 
 tissue aflected. Jhit it is to be remembered that no hard- 
 anc'-fast line of distinction really exists. Thus while endo- 
 cervicitis is studied by itself, it must not be forgotten that 
 there may be an accompanying inflammation in the en j- 
 mctrium above the cervix, or in the muscular part of the 
 wall. Also, in considering chronic metritis, while attention 
 may bo mainly fixed on the changes in the muscular 
 thicknesses of the wall, it is to be noted that the mucosa 
 or the peritoneal ct voring, or both, may also be inflamed. 
 
 As regards the etiology of the various forms of inflamma- i 
 tion, it is probably best to establish the following classi- \ 
 ficatior.t : — 
 
 Acute Inflammations. 
 
 These arc due to the following conditions : — • 
 
 1. Septic infection in the puerperium. 
 
 2. Septic infection in operative procedures. 
 
 3. Gonorrhoea. 
 
 4. Extension from neighbouring acute inflammation, e.g. 
 peritonitis. 
 
 5. Acute specific febrile conditions, e.g. typhus. 
 
 6. Excessive coitus and cold at a menstrual period are 
 believed to cause the condition sometimes. 
 
 Chronic Inflammations. 
 
 1. Following on an acute attack. 
 
 2. Infection after delivery, especially after imperfect 
 emptying of the uterus, and after lacerations. 
 
 3. Faulty asepsis in operative measures on the genital 
 tract. 
 
INFLAMMATION OF THE MUCOSA. 
 
 419 
 
 4. Extension of inflammation from neighbouring struc- 
 tures. 
 
 5. C'lOnorrhfca. 
 
 6. Associated with liic [)resence of uterine tumours. 
 
 7. Associated with too fretjuent child bearing, non-lac- 
 tation, too early rising after delivery. 
 
 8. Associated with retroversion. , • 
 
 9. Excessive coitus is said to be a cause. 
 10. Tuberculosis. 
 
 Varieties Studied in Detail. 
 
 I. INFLAMMATION OF THE MUCOSA. 
 
 CERVICAL MUCOSA, 
 
 •.?•• 
 
 ire 
 
 ct 
 
 Acuta Inflammation. 
 
 Acute endocervicitis is found with general acute inflam- 
 mation in the uterus, and will be considered under " Acute 
 Metritis." 
 
 Chronic Inflammation 
 (Chronic Cervical Catarrh, Cervical Endometritis, 
 
 Endocervicitis). 
 
 This form is especially due to infection following lacera- 
 tions of the cervix, and to spread from inflammation in the 
 endometrium of the corpus uteri. It is also found as a result 
 of gonorrhoea, and in retroversion of the uterus. 
 
 Pathology. — The inflammatory process affects all parts of 
 the mucosa, chiefly the glands and epithelium. 
 
 Hyperplasia and increased folding of the mucosa take 
 place, and extension below the os externum occurs, the 
 stratified epithelium around the latter being displaced. The 
 glands also increase and extend downwards in the cervix ; 
 their outlets may get closed, giving rise to retention cysts — 
 Nabothian follicles. One of these may grow beyond the 
 surface and become a polypus. Sometimes this projection 
 
 fi 
 
 %\ ■ 
 
V, 
 
 420 
 
 AFFECTIONS OF THE UTERUS. 
 
 Fig. 138. — Small bit of vaginal 
 portion of cervix with a large 
 Nabothian follicle. 
 
 may contain more than one small cyst. In some cases a 
 Nabothian follicle bursts through the surface, forming a 
 moist surface which tends to proliferate. When the disease 
 is extensive, the lower part of the cervix may become con- 
 verted into a mass of cysts. The connective tissue elements 
 
 are increased as the inflam- 
 mation proceeds, and the cervix 
 may be greatly thickened and 
 sometimes elongated. 
 
 On microscopic examina- 
 tion, the patches of inflamed 
 cervical mucosa present the 
 following appearances : — 
 
 I. The folds and recesses 
 may be long and narrow — the 
 papillary variety. 
 2. They may be short, the recesses being often broad and 
 irregular, formed by the bursting of retention cysts. In 
 both forms the covering epithelium is a single layer of 
 columnar cells smaller than those of the 
 normal mucosa. 
 
 In rare forms of inflammation the 
 superficial epithelium may be destroyed, 
 forming a true ulcerated surface. 
 
 Physical signs. — On physical exam- 
 ination various conditions may be found. 
 In a nullipara, if the disease is at all 
 marked, and has extended outside the 
 OS externum, the margins of the latter 
 feel soft and velvety; in a multipara, 
 in addition, the cervix and os are en- 
 larged, and there are evidences of laceration. Shotlike 
 nodules or larger masses, retention cysts, may be felt with the 
 finger. In some cases a cyst may be felt as a hard, raised 
 area on the surface (like early cancer), or as a polypoidal 
 projection. Occasionally the velvety area bleeds slightly on 
 
 Fig. 139. — Small 
 multllocular poly- 
 pus growing from 
 vaginal portion of 
 cervix. 
 
INFLAMMATION OF THE MUCOSA. 
 
 421 
 
 being pressed with the finger-nail. A good deal of mucus 
 may be felt about the os. 
 
 On examining the cervix with a speculum, the enlarge- 
 ment of the cervix is noted. The inflamed or catarrhal 
 patches appear as bright red, granular, secreting surfaces.^ 
 These areas of mucosa become soft and spongy. 
 
 Ssrmptoms. — There is marked leucorrhoeal discharge, 
 iT^ucous, thick, creamy, or variously coloured, with no offen- 
 oive odour usually. It may sometimes be tinged with blood. 
 
 There is usually pelvic distress, e.g. vague dragging pains, 
 or back and loin pains. These are aggravated on exercise. 
 
 Menorrhagia is found in some cases, probably mainly de- 
 pending upon the amount 
 of involvement of the mu- 
 cosa of the corpus uteri. 
 Irregularity of menstrua- 
 tion is often found. As 
 the patient gets more and 
 more run down, some de- 
 gree of amenorrhoea may 
 be found. 
 
 The disease tends to pre- 
 vent conception. 
 
 In many cases, the patient gradually loses health, gets 
 unfit for her duties, and may become neurasthenic. These 
 changes are more frequent, however, when the uterus is 
 widely affected. 
 
 DiflFerential diagnosis. — The condition must be diagnosed 
 from mere vaginal or vulvar leucorrhoea. 
 
 Endometritis may cause similar symptoms, but in the 
 latter condition none of the j^hysical signs relative to the 
 cervix may be present. 
 
 Early malignant disease of the cervix may stimulate 
 endocervicitis, i.e. in the hard feeling in the latter condition, 
 
 1 These patches liave also been known by the terms " erosion," "cctro- 
 piuni." For a long time they were wrongly thought to be ulcers. 
 
 ■^m-mmmi 
 
 •-0. 
 
 w^ 
 
 Fig. 140. — Endocervicitis, Section 
 through papillary form of catarrhal 
 patch. 
 
 r^ 
 
422 
 
 AFFECTIONS OF THE UTERUS. 
 
 due to Nabothian follicles. At a later stage the profuse 
 discharge might be mistaken for the leucorrhcea of endocer- 
 vicitis ; it is, however, often disagreeable in odour, and 
 mixed with more or less blood. 
 
 Simple laceration of the cervix may sometimes be wrongly 
 diagnosed as endocervicitis. This is apt to be the case if it 
 be examined with a tubular or valvular speculum. The 
 OS may appear gaping, and a red velvety area be seen, 
 resembling the catarrhal patch ; this is merely the normal 
 mucosa, exposed by the separation of the edges of the tear 
 in the cervix. If, in such a case, the edges be brought 
 
 Fig. 141. — Endocervicitis. Section through follicular form of . 
 catarrhal patch. 
 
 together by volselloe, the redness disappears, whereas in a 
 true catarrhal patch it cannot be made to disappear in this 
 way. 
 
 LxUCOSA OF 'ORPUS UTERI. 
 
 Acute Inflammation (Acute Endometritis). 
 
 This inflammation is usually part of one affecting the 
 whole uterus, and will be considered along with "acute 
 metritis." 
 
 Chronic Inflammation (Chronic Endometritis). ' 
 
 Pathology. — The inflammatory changes affect the glands, 
 the lining epithelium and the interglandular tissue. Accord- 
 
 I V 
 
ACUTE ENDOMETRITIS. 
 
 423 
 
 ing to the predominance of the tissue affected, the varieties 
 are denominated. Thus, Ruge makes the division as 
 follows : — 
 
 Glandular. 
 
 Interstitial. 
 
 Mixed. 
 
 In the gla'idular variety, there is both a hypertrophy and 
 hyperplasia of the glands, the latter taking place mainly by 
 lateral outgrowths of old glands ; it is doubtful if new ones 
 grow inwards from 
 the surface epithe- 
 lium, as some state. 
 
 Many of the 
 glands have, on 
 longitudinal sec- 
 tion, a serrated ap- 
 pearance. 
 
 In the interstitial 
 variety, the inter- 
 glandular connec- 
 tive tissue elements 
 are most affected. 
 
 The ordinary chronic changes in inflammation are found, 
 the tendency to the formation of spindle-shap; d cells and 
 dense tissue being prominent. The glands may become 
 pressed upon and obliterated. Sometimes small retention 
 cysts are formed. These may sometimes cause projections 
 of the surface. 
 
 In mixed forms, the above changes are found in various 
 proportions. 
 
 In old-standing endometritis the mucosa gets atrophied and 
 gradually destroyed, being replaced by firm connective tissue. 
 
 Opposite sides of the lumen may blend, sometimes 
 causing complete atresia. These changes may sometimes 
 be seen in the senile uterus, in which accumulation of 
 mucus or blood may take place above the atresia. 
 
 
 Fig. 142. — Glandular endometritis. 
 
V, 
 
 424 
 
 AFFECTIONS OF THE UTERUS. 
 
 Fig. 143. — Chronic interstitial endo- 
 metritis. The mucosa is greatly 
 altered from the normal. 
 
 Occasionally inflammation in the mucosa leads to a 
 destruction of the lining epithelium, and to the formation 
 of projections of granulation tissue — the so-called villous or 
 
 papillary endometritis. 
 ^^^I^^;??) These may give rise to 
 small polypi. 
 
 In some cases of en- 
 dometritis there is a 
 special tendency to 
 marked congestion, and 
 dilatation of the blood 
 vessels. 
 
 This variety is known 
 as hemorrhagic etido- 
 metritis or endometritis 
 fuftgosa. 
 
 It may be extremely difficult to say which one of these 
 conditions is present in most cases of the affection. 
 Microscopic examination of scrapings is important in 
 enabling one to 
 arrive ai a con- 
 clusion. 
 
 When endome- 
 tritis occurs soon 
 after the pregnant ;^ 
 uterus is emptied, 
 especially after an 
 abortion, the con- 
 nective tissue cells 
 tend to be of large 
 size — the decidual 
 type, for some time. This is more apt to lie pronounced it 
 the uterus has not been thoroughly emptied. \ 
 
 Physical signs. — The uterus is enlarged considerably, 
 usually, if there be much associated metritis. 
 
 It may not be easy to make out slight degrees of enlarge- 
 
 
 Fig. 144. 
 tion. 
 
 -Endometritis following an abor- 
 Large decidual cells are seen. 
 
 (\. 
 
ACUTE ENDOMETRITIS. 
 
 425 
 
 ment by the bimanual ; this can be determined by the 
 passage of the sound. On introducing this instrument, 
 slight bleeding may result ; there may be tenderness, and 
 irregularities may be felt. In many cases, however, none of 
 these signs are present. 
 
 Endocervicitis may often be present, or other conditions, 
 e.g. cellulitis, local peritonitis. 
 
 Differential diagnosis. — The hcemorrhagic type may be 
 mistaken for sarcoma, or carcinoma of the uterus. It may 
 be difficult to say which of these conditions is present 
 without the most careful examination of scrapings. 
 
 Symptoms. — Increased menstruation is the most common 
 symptom. This is especially marked in the hremorrhagic 
 type, and, as a result, the patient may get very anaemic, 
 weakened, and sometimes cachectic-looking. There may be 
 increase both in the duration and quantity, and in some 
 cases there may be loss of blood between times. When 
 the patient has got much run down, the menstruation may 
 become scanty. 
 
 Leucorrhcea is very common. The discharge is not 
 usually so gelatinous as that produced by the cervix. It is 
 more serous or seropurulent, and may be somewhat blood- 
 tinged. 
 
 Dysmenorrhoea is frequently present. In some cases this 
 is undoubtedly due to associated inflammatory conditions, 
 e.g. metritis, salpingitis, etc., but in many cases I believe it 
 to be due to abnormal clotting of blood /« utero^ fibrin- 
 formation, or to the shedding of abnormally large bits of 
 mucosa, as a result of the inflammatory changes ; these 
 masses interfere with the free escape of the menstrual blood 
 and cause reflex contractions of the uterus {inde " Dys- 
 menorrhoea," p. 127). 
 
 Weakness and pains in the back and pelvis arc common. 
 A feeling of general weakness and incapacity for work, 
 anaemia, various nervous derangements, and digestive dis- 
 orders are found in well-pronounced cases. 
 
\\ 
 
 426 
 
 AFFECTIONS OF THE UTERUS. 
 
 Sterility may result, or if pregnancy should take place 
 there is a tendency to abortion. 
 
 
 
 A..-*.. 
 
 J / :••' i '-^ 
 
 \\ 
 
 II. INFLAMMATION OF THE WHOLE UTERINE WALL. 
 
 Acute Metritis. 
 
 Pathology. — In acute inflammation the uterus becomes 
 enlarged, softened, and, it may be, of doughy consistence. 
 The walls are deeply congested in all parts, and blood 
 extravasations may be seen in parts. 
 
 Inflammatory products are exuded among the muscular 
 
 bundles, and in the mucosa. If 
 "■'*^'- pus formation has taken place, 
 small foci are noticed throughout 
 the wall. The muscle is softened, 
 and often pulpy. The peritoneal 
 surface is also inflamed. 
 
 Acute metritis may lead to a 
 chronic inflammatory condition, 
 in which thickening and hardening 
 of the connective tissue elements 
 prevail ; or, a chronic purulent 
 condition may be left, abscesses 
 being present in the uterine wall, and, sometimes, in the 
 adjacent parametrium, tubes, and ovaries. Rarely, abscess 
 of the wall may perforate into vagina, bladder, intestines, or 
 abdominal walls. 
 
 Sometimes rapid resolution and recovery may occur. 
 At times death occurs from the virulence of the infection 
 causing the inflammation. 
 
 Physical signs. — There is tenderness on bimanual exam- 
 ination of the pelvis, and there may be great pain. The 
 abdominal walls may be very tense and resistant — varying 
 according to the amount of peritonitis. There is much 
 heat in the pelvis, and often free leucorrhoeal discharge. In 
 puerperal cases, the lochial discharge usually diminishes 
 
 Fig. 145. — Septic infection 
 following abortion. Many 
 chains of streptococci are 
 seen in the remains of the 
 mucosa of the uterus. 
 
 t V 
 
CHRONIC METRITIS, 
 
 4*7 
 
 with the development of an acute attack. The uterus is 
 felt enlarged and softened. The usual signs of peritonitis 
 may be present also. 
 
 Symptoms. — These are in general those of acute local peri- 
 tonitis. There is, locally, a feeling of heat and fulness ; 
 pains are felt in the pelvis, aggravated by movement, 
 micturition, and defalcation. There is vesical and rectal 
 tenesmus. 
 
 Menstruation is usually suppressed or diminished, some- 
 times increased. 
 
 v\ 
 
 Chronic Metritis. 
 
 Pathology. — This condition may follow an acute inflam- 
 matory attack, but more frequently it begins slowly. When 
 it follows an acute process, or begins as a subinvolution 
 after the delivery, the uterus is at first enlarged, softened, 
 and congested. Later it becomes gradually indurated and 
 pale. The enlargement is uniform. The peritoneum may 
 or may not form adhesions. 
 
 On microscopic examination, in the early stage, the 
 vessels are found congested, and many leucocytes and 
 proliferating connective tissue corpuscles are found between 
 the muscular bundles. Later on, the blood vessels are 
 contracted and their walls thickened, the lymphatics often 
 dilated. There is an increased quantity of dense fibrous 
 tissue between the muscular bundles. The latter gradually 
 tend to become compressed and destroyed. 
 
 In the endometrium the various chronic inflammatory 
 changes described may be in process. The peritoneum 
 may be found thickened or adherent. 
 
 Physical signs. — In the early stage the uterus is felt 
 bimanually to be uniformly enlarged and somewhat softer 
 than normal. In the later stages it is felt enlarged and 
 hard. It may be movable, fixed, or displaced. On 
 passing the sound, its cavity is found to be enlarged. 
 
 v\n. 
 
428 
 
 AFFECTIONS OF THE UTERUS. 
 
 Differential diagnosis. — It is often clifTicult to establish a 
 diagnosis between metritis, early pregnancy, metritis in an 
 early pregnant uterus, and a uterus enlarged as a result of 
 a small fibromyoma. 
 
 Symptoms. —Menstruation is altered in various ways, 
 mainly depending upon the condition of the endometrium. 
 JVIenordvigia and metrorrhagia are very frecjuent. The 
 discharges of blood may be very irregular in some cases. 
 When the i)atient is much run down, there may be some 
 degree of amenorrhiea. 1 )ysmen()rrh(ea is often present. 
 'I'here is a tendency to abortion. In marked cases sterility 
 is the rule, though in many cases this may be due to 
 coexisting inflammatory changes in the ovaries or tubes, 
 'i'here is a feeling of weakness, dragging, or heaviness in 
 the back, pelvis, or loins, and pains are often felt. There 
 may be pain on defiecation and micturition. 
 
 'I'here are usually more or less marked reflex and sym- 
 pathetic disturbances, and various neuroses may be estab- 
 lished. 
 
 TuKArMKNT OF UlERINK INFLAMMATIONS. 
 
 ' In Acute Cases. 
 
 The treatment of acute inflammation of the whole uterus 
 is practically that of an acute pelvic peritonitis. 
 
 If there be any local cause of sej)tic infection, e.g, 
 remains of placenta which have undergone decomposition 
 /■// utcro, the cavity of the uterus should be thoroughly 
 curetted and washed out regularly with an antiseptic lotion. 
 
 Several have advotwted extirpation of the uterus in acute 
 se[)tic, i\i^. j)uerperal cases ; the operation is a very severe 
 one under the circuuiistances, and it is doubtful if it should 
 be employed. If the treatment of septicccmia by anti- 
 streptococcus serum turns out to be reliable and successful, 
 it is likely that such extreme operative measures will never 
 come under consideration. 
 
 } 1 
 
TREATAfRNT OF INFLAMMATIONS. 
 
 m 
 
 In Ohronic Oajses. 
 
 The treatment of chronic uterine inflammation is most 
 (lirfieult and unsatisfactory. It can only be satisfactorily 
 accomplished when the patient submits herself to the 
 most diligent carrying out of the measures recom- 
 mended. vS[)asmodic or unsystematic efforts arc bound 
 to end only in disappointment both to patient and 
 physician. 
 
 Gknkral Measures. — It is of the greatest importance 
 to attend to the general health of the patient. The diet 
 should be regulated so that the stomach and bowels 
 perform their functions well. Constipation is to be 
 avoided. Various mineral waters are used for laxative 
 purposes, e.g. Villacabras, Rubinat, Birmcnstorf, Hunyadi 
 Janos, Friedrichshall. If the patient be run down, it may 
 be necessary to stop her from engaging in her ordinary 
 activities. Often it is best to send her away from home 
 for a com[)lete change. Patients often improve consider- 
 ably at watering-places, where they are under changed 
 conditions and on strict regimen. Sometimes it is advis- 
 able to make the patient rest on the flat of her back, 
 with the lower part of her body elevated, for a couple 
 of hours in the afternoon. She must not be allowed to 
 become too inactive, however, and should be encouraged 
 to take regular open-air exercise of a gentle nature, while 
 indoor practice with dumb-bells or Indian clubs should be 
 enjoined. 
 
 At menstrual periods the patient should take an extra 
 amount of rest. Coitus is to be avoided as much as 
 possible. 
 
 Certain drugs may be necessary in some cases, mainly 
 of a tonic nature, e.g. iron, arsenic, cod-liver oil, strychnine. 
 Potassium or sodium iodide is recommended strongly by some 
 authorities to bring about a reduction in size of the uterus, 
 but it acts very slowly in this way, if local pelvic measures 
 
 ! 
 
 
w 
 
 430 
 
 AFFECTIONS OF THE UTERUS. 
 
 be not employed ; it may be especially valuable where 
 there is a rheumatic taint, but it is not to be used if the 
 patient be much depressed or debilitated. Sodium or 
 potassium bromide is often used along with the iodide, 
 where there is much pain or nervous irritability. It is 
 important, however, to avoid the indiscriminate use of this 
 drug, and it should be withheld in all cases where there 
 is a considerable neurotic complication. 
 
 Various of the medicinal waters are of value in many 
 cases, e.g. the sulphated alkaline waters of Franzenbad, the 
 muriated waters of Kreuznach, Woodhall Spa, Kissingen, 
 Reichenhall, the muriated alkaline waters of Ems, Royat, 
 etc. Iron waters are given at Spa, Schwalbach, Pyrmont, 
 and elsewhere. 
 
 When there is menorrhagia or metrorrhagia, ergot may 
 be given for some weeks, being increased at the menstrual 
 periods. 
 
 In every instance the patient should be encouraged and 
 strengthened in every way ; she should be made to take 
 her mind off her local condition. If she be very neurotic, 
 strict disciplinary measures may be necessary, and, in some 
 cases, it is advisable to put her under the Weir Mitchell 
 treatment. 
 
 Believing that the great majority of these chronic inflam- 
 mations are due to residual infection of microbial origin, 
 we must use measures to promote nature's method of get- 
 ting rid of the irritant, mainly by the activity of the blood 
 and lymph circulation, and of leucocytes. 
 
 Local Measures. — It is important, therefore, to aim at 
 relief of congestion and stimulation of the circulation. 
 Where the uterus is somewhat enlarged and tends to drag 
 down or prolapse, a Hodge or ring pessary may be intro- 
 duced to support the uterus as a whole for a time. This is 
 especially necessary if the uterus be displaced. 
 
 Vaginal douching is of great value when thoroughly 
 carried out i^ide p. 216). The water may be either cold or 
 
 » \ 
 
TREATMENT OF INFLAMMATIONS. 
 
 431 
 
 it- 
 )d 
 
 |y 
 
 hot. Most patients prefer the latter, the temperature being 
 about no" F. 
 
 When there is slight endometritis and endocervicitis it is 
 well to finish the douche with an astringent lotion, e.g. 
 sulphate of copper or alum (3ii. to a pint) solution, or 
 corrosive sublimate (i to 6000), solution. 
 
 Hot hip-baths of salt water given at night from time to 
 time are serviceable. They are often valuable in diminish- 
 ing pelvic pain, especially before menstruation. If the 
 patient is debilitated, it is not well to employ them. 
 
 A cold hip-bath in the morning is a valuable stimulus to 
 the circulation. Vaginal tampons soaked in glycerin or in 
 ichthyol glycerin (i in 10-20), placed in the vagina 
 against the cervix, at bed-time, may relieve congestion 
 considerably by causing a free flow of watery discharge 
 from the uterus. These may be introduced every few 
 nights. 
 
 When the leucorrhaal discharge is not checked by these 
 measures, applications of iodised phenol, perchloride of 
 iron, or glycerin and carbolic acid in equal parts, may be 
 made in the interior of the uterus two or three times during 
 the course of a month. It is best to begin during the week 
 after menstruation. If an application be made too near the 
 onset, it is apt to bring on the flow prematurely. 
 
 Counter-irritation by means of blisters over the iliac 
 regions is often beneficial. 
 
 In many cases it is more expeditious to curette the 
 uterus thoroughly. The importance of thorough removal 
 of possible sources of infection in inflammations of the 
 uterus cannot be too strongly urged. If a diseased mucosa 
 be left as a constant source of irritation, progress will be 
 very slow. Where slight endocervicitis exists, with the for- 
 mation of a catarrhal patch, the diseased surface should be 
 scraped away, the Nabothian follicles emptied, and iodised 
 phenol applied. Each day afterwards the vagina should 
 be douched with an astringent antiseptic douche. In bad 
 
432 
 
 AFFECTIONS OF THE UTERUS, 
 
 cases, where the cervical mucosa is much diseased, curetting 
 should be followed by an operation for the removal of the 
 diseased part. This is best carried out by Schroeder's 
 method, as follows : — • 
 
 The cervix is drawn down and steadied with a volsella. 
 It is then divided as high as the fornix into an anterior and 
 posterior half. A transverse incision is then made across 
 the mucosa of the latter above the disease, and another is 
 carried up from the extremity of the lip to meet the first 
 one. In this way a strip of diseased mucosa is entirely 
 
 -Operation for removal of diseased mucosa in 
 endocervicitis. — Schroeoer. 
 
 I. The lines of incision are shown. 2. Passage of sutures. 
 
 removed. The rawed lip is then bent upwards on itself, 
 the lower part being approximated to the intact mucosa, and 
 three or four stitches applied. 
 
 The anterior lip is treated in the same way. The 
 sides of the first incision are then secured with a stitch 
 or two, and the after-treatment is the same as in the case of 
 curetting. 
 
 In bad haemorrhagic endometritis cases, it is good, after 
 curetting, to pack the uterine cavity with iodoform gauze 
 for twenty-four hours, and then to introduce another piece 
 for the same period. 
 
 I \ 
 
STENOSIS OF THE CERVICAL CANAL. 
 
 433 
 
 After these operations the patient should be in bed for at 
 least eight day? At the following menstrual period there 
 is apt to be an excessive discharge of blood, and it is 
 advisable for the patient to rest a good deal and to take 
 ergot inwardly. 
 
 In extreme cases of metritis, where the uterus is much 
 enlarged, in addition to curetting the mucosa it is advisable 
 to amputate one or both lips of the cervix by the method 
 described on p. 438. This has been especially advocated 
 by Martin of Berlin as a means of stimulating involution 
 changes in the uterus. 
 
 Galvanic electricity is also valuable in reducing the size 
 of the uterus {vide p. 241). 
 
 In cases where acute metritis has been followed by a 
 purulent condition in different parts of the wall, extirpation 
 of the uterus along with the tubes and ovaries, which may 
 be similarly affected, is justifiable. The operation is 
 usually best carried out by the clamp-method. 
 
 i.. 
 
 d 
 
 Stenosis of the Cervical Canal. 
 
 Narrowing of the cervical canal may be found at the os 
 externum, the os internum, at both of these spots, or in the 
 whole length of the canal. Most frequently the first f'vo 
 varieties are found. The condition may be a congenital 
 one, and in these cases it may be found with defective 
 development of the uterus, or with an elongated cervix. It 
 may be due also to contracture after labour, after operations 
 on the cervix, e.g. amputation, to frequent application of 
 strong caustics ; it may sometimes follow inflammatory 
 changes in the cervix. The irritation of a pessary has been 
 known to lead to it. It may be a natural change in advanc- 
 ing age. 
 
 Symptoms. — Dysmenorrhoca may be caused. Normally, 
 during menstruation, some dilatation of the cervical canal 
 takes place. If this be prevented it is possible that the 
 28 
 
V. 
 
 434 
 
 AFFECTIONS OF THE UTERUS. 
 
 ohslriKlion to the menstrual outflow may lead to the de- 
 velopment of pains. " 
 
 In many of these cases the pains are due to associated 
 conditions, e.g. clotting of the blood in utero, fibrin-forma- 
 tion, the shedding of abnormally large bits of uterine mucosa 
 as a result of endometritis, inflammatory changes in the 
 uterine wall. 
 
 Often the pains are due to a neurotic condition. (For a 
 full consideration of dysmenorrhea in relation to stenosis 
 of the cervix, vide p. 125.) 
 
 Sterility may also be common in these cases, but 
 probably, in many instances, it is not the stenosis but 
 some associated condition, e.g. inflammation, which is the 
 cause. Neurotic comj)lications are often present. 
 
 Physical examination. — The condition of the cervix may 
 sometimes be distinguished by the finger when the os 
 externum is affected. It is usually xiecessary to use the 
 sound. This may be passed with great difficulty, or it may 
 be inij)ossible. Sometimes the cervical canal may become 
 disteiKk d with mucus when the stenosis is at the . os 
 externum. 
 
 It is important to note that the sound may be obstructed 
 by a uterine flexion, a fold of the mucosa, a polypus, or 
 by a reflex contraction of the muscle around the os 
 internum. 
 
 Treatment. — When there is a stenosis of the cervical 
 canal, some method of permanently enlarging it should be 
 adopted. This treatment should always be associated with 
 energetic measures to improve other diseased conditions 
 which may be i)resent. Generally it is well to curette 
 the uterus where there are inflanmnatory changes in its 
 wall. 
 
 The following are the various operative measures to be 
 /ecommended : — 
 
 Instrumental dilatation. — The i)atient is prepared for 
 operation as described on p. 205. She is placed in the 
 
 / ' 
 
 . ^^ 
 
STENOSIS OF THE CERVICAL CANAL. 
 
 435 
 
 )r 
 
 He 
 
 lithotomy position and anaesthetised. The cervix is pulled 
 down by means of a volselk. The size of the canal is 
 estimated by the sound, and a series of Hegar's dilators are 
 passed into the cervical canal until the stenosed portion 
 is well stretched. Along with these a metal dilator, e.g. 
 Sims', may be used. 
 
 Incision. — It is generally best to divide the stenosed 
 portion as well as to dilate it. In the case of a small ex- 
 ternal OS, this may be carried out with a pair of scissors 
 or an ordinary bistoury, the cervix being pulled down with 
 a volsella. 
 
 The posterior lip may be divided in the middle line, or 
 the cervix may be divided on each side. The depth of the 
 incision is about three-eighths of an inch. 
 
 In the case of stenosis of the whole canal or of the internal 
 OS, after dilatation a narrow, sharp-pointed bistoury is passed 
 up the cunal, and the wall at the internal os incised first 
 on one side and then on the other. If the whole cervical 
 canal is narrowed, each of these incisions can be extended 
 down through the whole length of the cervix. The incision 
 extends through the whole thickness of the mucosa and into 
 the muscle. 
 
 The after-treatment in these cases is important. The 
 rawed surfaces should be swabbed with iodised phenol or 
 liquor ferri perchlor. fort., and they should be kept apart 
 by a small glass tube, or by a plug of iodoform gauze, 
 'i'hese should be changed every two days for eight days. 
 Afterwards, for teii days, the os should be kept open by 
 means of Hegar's dilators or the finger. 
 
 Excision. — In cases of stenosis of the external os, this 
 operation is preferred by some. 
 
 The cervix is pu' ^ down with a volsella, and if, split on 
 each side for half a. ich. Out of c'ach of these portions a 
 wedge-shaped pi^ce is cut with a sharp bistoury. The raw 
 surfaces in each lip are then closed by catgut sutures, the 
 edge of the cervical mucosa being joined to that of the 
 
^ 
 
 436 
 
 AFFECTIONS OF THE UTERUS. 
 
 vaginal portion. The lateral incisions are then closed. At 
 the end of the operation, instead of the small os externum 
 there is left a large gaping one. 
 
 After these operations, it is a good thing to pass a 
 dilator or sound into the uterus prior to three or four mens- 
 trual periods. Neurotic complications must be carefully 
 attended to. 
 
 Atresia of the Cervix. 
 
 This may be congenital or acquired. The former of 
 these is considered on p. 416. 
 
 Acquired atresia may follow cicatrisation after injury ii) 
 labour, cauterisation of the cervix, amputation, ulceration ; 
 it may be found in the senile uterus ; with tumours of the 
 cervix ; as a result of the irritation of a pessary ; sometimes 
 in prolapsus uteri. 
 
 If the patient has not passed the menopause, distension 
 of the uterus or tubes, or of both, may result. Son. times 
 this may become infected, and a collection of pus may 
 follow ; occasionally it may contain gas. In women, after 
 the menopause, a pus collection may rarely be found in the 
 uterus. 
 
 Treatment. — An opening must be made in the cervix. 
 The incision is made by means of a sharp bistoury, the 
 cervix being steadied by means of a volsella. A small 
 circular portion may be cut out, and the raw surfaces 
 swabbed with perchloride of iron. T>e after-treatment is 
 important. A glass tube should be worn for a few weeks, in 
 order to prevent the part from closing. 
 
 HVPERTROPHV OF THE CeRVIX. 
 
 V 
 
 Hypertrophy of the uterus is found in two forms, namely, 
 general increase in size, especially transversely, due to in- 
 flammation, and hypertrophic elongation. The latter will 
 
 '^ r 
 
HYPERTROPHY OF THE CERVIX. 
 
 437 
 
 rvix. 
 the 
 nail 
 ices 
 is 
 in 
 
 I in- 
 fill 
 
 Fig. 147. — Hypertrophic 
 elongation of vaginal 
 portion of cervix. 
 
 alone be considered under this heading. The following 
 forms are met with : — 
 Hypertrophic elongation of the vaginal portion. In 
 
 this condition the portion of the cervix witiiin the vagina is 
 elongated ; in some cases it may extend beyond the vulva. 
 There is practically no transverse in- 
 crease. This condition is probably 
 congenital in origin. 
 
 Physical signs. — On bimanual ex- 
 amination the fundus uteri is found 
 at its normal height. The fornix 
 vaginae is normal. The uterus is elon- 
 gated, that part of it above the 
 vagina being of normal size and 
 shape. 
 
 Hjrpertrophy of the supravaginal portion. — This con- 
 dition may be primary, though generally it is secondary to 
 prolapsus uteri. 
 
 Physical signs. — On bimanual examination the uterus is 
 
 felt elongated. As the hypertrophy 
 increases, both fornices tend to be- 
 come obliterated. It is impossible to 
 say whether the body of the uterus 
 may not be involved in these cases, 
 because it is impossible to know 
 clinically where the os internum is 
 situated. There may be stenosis of 
 Fig. i48.-Hypcrtrophic ^^e cervix. In an advanced case the 
 elongation of supra- bladder is greatly lowered, as well as 
 
 vaginal portion of t^g pouch of Douglas. 
 
 ^*^'^^'^' Hypertrophy of the intermediate 
 
 portion. — Sometimes the hypertrophy may mainly affect the 
 intermediate portion of the cervix. As it increases, the 
 anterior fornix tends to become obliterated, the posterior 
 remaining. The bladder becomes lowered. 
 
 Symptoms. — In slight cases there may be no symptoms. 
 
 %^ 
 
438 
 
 AFFECTIONS OF THE UTERUS. 
 
 : i 
 
 In other cases there may be dysmenorrhoea and sterility. 
 In marked cases there may be a feeling of dragging or 
 bearing down, discomfort, or pain. There may be micturi- 
 tion and defiecation troubles, and trouble on walking. 
 Leucorrhoca may be excessive, and may result from irritation 
 of the vaginal walls. If the cervix projects from the vulva 
 it may become ulcerated. 
 
 Treatment. — Amputation of the cervix must be carried 
 out. 
 
 Hyi>ertrophic Elongation of thk Cervix. 
 
 Amputation of part of the cervix is performed. Either of 
 two methods may be employed. 
 
 I. Flap amputation, by removal of wedge-shaped portions 
 from anterior and posterior lips. 
 
 The patient is placed in the lithotomy position. A short, 
 
 wide, spatular speculum is placed 
 posteriorly in the vagina. The cervix 
 is pulled down with a volsella. The 
 length of the uterine cavity is meas- 
 ured, so that the amount of tissue to 
 be removed may be estimated. The 
 cervix is then divided on each side 
 as high as is desired, it may be 
 I in. or more. In this way the 
 of anterior and posterior lips arc separ- 
 ated. 
 
 The posterior lip is then held in the middle line at its 
 lowest point by a volsella, the anterior lip being held out of 
 the way by an assistant. With a bistoury a transverse cut is 
 made across the posterior lip some distance below the upper 
 limit of the lateral incisions. The edge of the bistoury cuts 
 inwards and upwards. A second transverse incision, begin- 
 ning on the lower part of the lip outside the os externum, 
 extends upwards to meet the first transverse cut. In this 
 way a wedge-shaped piece of tissue is removed. 
 
 Fig. 149. — Hypertrophic 
 ck)n};;ition of inter- 
 niodiate portion 
 c«rvix. 
 
ELONGATION OF THE CERVIX. 
 
 439 
 
 The raw surfaces in the lip are then brought together, 
 tlic mucosa of the cervical canal being approximated to that 
 of the vaginal portion of the cervix. l'"or this a series of 
 interrupted catgut sutures are used, 
 or a continuous suture may suftice. 
 
 A corresponding wedge-shaped 
 
 portion is then removed from the 
 
 anterior lip, and the raw surface 
 
 closed. The anterior and posterior 
 
 lips are then brought together by 
 
 means of a catgut suture passed on 
 
 each side. The sutures are then 
 
 cut short. 
 
 ... ^, ,. Ill- Fig. 150. — Flfip amputation of 
 
 Durmg the operation bleedmg cervix.--MARTiN. 
 
 is checked by means of the hot 
 
 douche which is used to irrigate the parts. Any marked 
 
 vessel may be twisted or secured with catgut. 
 
 A vaginal plug of iodoform gauze is placed in the vagina, 
 and the patient is put to bed. After twenty-four hours the 
 
 plug is removed, and an anti- 
 septic warm douche is given. 
 This is repeated daily. By the 
 tenth day the patient may sit up. 
 2. Circular amputation. — ■ 
 The cervix is pulled down with 
 a volsella attached close to the 
 OS externum. With a bistoury a 
 Fig. i5i.-Appearance of cervix circular incision is made through 
 iniinediately after Hap ampu- , , 
 
 ^j^jJq^ the mucous membrane, covermg 
 
 the vaginal portion of the cervix 
 just where the outer surface turns inwards towards the os 
 externum. The mucous membrane is stripped upward 
 above this incision by means of the thumb-nail and knife, 
 leaving bare the musculature of the uterus. The upper 
 limit is decided by the amount to be amputated. The 
 cervix is then divided into '^" anterior and a posterior part; 
 
 i \l 
 
440 
 
 AFFECTIONS OF THE UTERUS. 
 
 \ 
 
 'I! 
 
 as high as the line of amputation. The posterior lip is then 
 cut across somewhat obliquely, so as to leave a thin flap 
 next the cavity. The stripped-up mucosa is then turned 
 over the stump, and its edge stitched to the thin flap next 
 the cervical canal. Separate catgut sutures are used. 
 
 The anterior lip is treated in the same way. On each 
 side of the canal the gaping redundant portions of the 
 stripped-up mucosa should be closed by catgut sutures. 
 Finally the cervical canal should be examined to see that it 
 has not been closed by sutures nor made too small. 
 
 The after-treatment is the same as described for the last 
 operation. 
 
 In those cases in which the relations of the bladder and 
 
 Fig. 152. — Diagram to show the method of amputating 
 the cervix by the circular method. 
 
 pouch of Douglas are altered, care must be taken not to 
 open into them in operating. 
 
 Atrophy of the Uterus. 
 
 This condition is found — 
 
 1. As a congenital condition {vide p. 411). 
 
 2. Associated with certain debilitating conditions, e.g. 
 chlorosis, tuberculosis, syphilis, diabetes, Bright's disease, 
 morphinism, etc. 
 
 3. After the menopause. 
 
 4. After delivery, as a result of superinvolution. Here 
 great loss of blood or over-iactation may lead to the con- 
 
LACERATION OF THE CERVIX. 
 
 441 
 
 hen 
 flap 
 ned 
 lext 
 
 ach 
 the 
 res. 
 It it 
 
 last 
 
 and 
 
 V 
 
 dition ; or, perhaps, pelvic inflammation causing destruction 
 of the ovaries or interfering gradually with the nutrition of 
 the uterus. 
 
 5. Sometimes it follows amputation of the cervix. 
 
 Pathology. — The uterus is reduced in size. The cavity 
 may be under 2 in. in length. I'he walls may be very thin 
 and flaccid, or tough and fibrous. The ovaries may or may 
 not be atrophied. 
 
 Diagnosis. — The chief feature is amenorrhoea. There may 
 be associated pelvic pains due to accompanying inflamma- 
 tory conditions or to neurosis. There may be a poor con- 
 dition of health and reflex neurotic phenomena. 
 
 On physical examination, the uterus is found to be small. 
 This is also made out by means of the sound, which must 
 be used with great care. The condition must be dis- 
 tinguished from malformations of the uterus. 
 
 Treatment. — Treatment is unsatisfactory. The general 
 health must be improved and tonics administered, e.g. iron, 
 strychnine. Locally, hot douches may be used. The 
 uterus may be stimulated by the frequent passage of a 
 sound. 
 
 to 
 
 3e, 
 
 Laceration of the Cervix. 
 
 Pathology. — Lacerations result from labour, especially 
 from a tedious or precipitate labour, or from operative pro- 
 cedures on the uterus. The former are by far the most 
 common cause. They n ay occur at an early abortion, as well 
 as at a labour in the late period of pregnancy. Lacerations 
 may be found in all parts of the cervix. Most commonly 
 the left anterior portion is torn (to be associated with the 
 most common position of the head in labour, namely, to the 
 front and left side). Very frequent is a double laceration, 
 one in front and on the left, the other behind and on the 
 right. Sometimes the presence of several tears may give a 
 stellate appearance to the cervix. All degrees of laceration 
 
44* 
 
 AFFECTIONS OF THE UTERUS. 
 
 may be found, from a slight notch to a deep fissure extend- 
 ing into the fornix. 
 
 Results of laceration, ~\\\'^^x\\x\\dX\id\\ of the mucosa of the 
 cervix, suijstancc of cervix, broad or utero-sacral ligament 
 and subinvolution may follow the lesion. It is thus evident 
 that a variety of conditions may be met with, 
 
 It is probable that the condition per se is of no signifi- 
 cance. Inasmuch, however, as it affords a raw surface for 
 germ activity and absorption, it is to be regarded as fur- 
 nishing an important area for the infection of the pelvis. 
 
 Symptoms. — Per se laceration gives rise to no symptom, 
 save to haemorrhage when the lesion occurs. 
 
 The many symptoms which are found are probably en- 
 tirely due to the secondary results of infection, I.e. cellulitis, 
 uterine inflammation, compression of nerves by cicatrisation 
 following inflammation, etc. They are very varied, e.g. 
 menorrhagia, metrorrhagia, leucorrhoea, pelvic pains and 
 aches, reflex and neurotic disturbances. 
 
 Emmet attaches great importance to the presence of 
 cicatricial tissue in the angle of the tear as a source of 
 pain and of nervous disorders. 
 
 Diagnosib. — On bimanual examination the laceration may 
 be felt. If the laceration be large or double and the mucosa 
 everted, the fingers may not so easily detect the condition. 
 Through a speculum the exposed mucosa is visible. If 
 there be no catarrhal patch, the red area can be made to 
 disappear if the torn edges of the cervix be brought together 
 by means of volsellse. Where catarrh exists the red area 
 cannot thus be made to disappear entirely. When inflam- 
 matory changes have resulted from the laceration, the 
 various signs due to them may be made out on physical 
 examination. 
 
 Treatment. — All marked lacerations should be repaired 
 at the time of their occurrence. Slight ones may be left 
 alone, but the raw surfaces should be kept aseptic until they 
 are healed, in order to prevent infection. 
 
LACERATION OF THE CERVIX. 
 
 443 
 
 In old-standing cases the most important treatment is 
 that which is directed towards the cure of the sequeU\j of 
 laceration {vide "Treatment of Uterine Inllammation and 
 Cellulitis"). 
 
 Repair of the laceration is rarely needed. It should be 
 carried out when there is much exposure of the cervical 
 mucosa. 
 
 The operative procedures are carried out as follows : — 
 
 (rt) Where the tear does not extend into the fornix. — A 
 spatular speculum is introduced 
 into the vagina for the purpose 
 of pulling back the posterior wall. 
 If there be endometritis, the 
 uterus should be curetted and 
 iodised phenol should be ap- 
 plied to the endometrium. Thj 
 cervix is then pulled down, the 
 edges of the tear are pared, 
 care being taken to raw the 
 apex well. A bistoury or pair of 
 scissors is used. The rawed sur- 
 faces are then brought together 
 by a series of catgut sutures. 
 The cervical canal should not be 
 made too small. 
 
 An iodoform gauze plug is placed in the vagina for 
 twenty-four hours. The after-treatment is the same as 
 described for the last operation. 
 
 {b) IF/ien the tear extends into the fornix^ displacement of 
 the litems having resulted from the cicatrisation.- — A broad 
 spatular speculum is placed against the posterior wall. The 
 uterus is curetted if there be endometritis. The cervix is 
 pulled -.vith a volsella towards the sound side. A curved 
 incision is made in the affected fornix close to the cervix, 
 and following its curve, some of the cicatricial bands being 
 cut through. As the cervix is pulled, the incision gapes. 
 
 Fig. 153. — Emmet's opera- 
 tion for repair of laceration 
 of the cervix. The dia- 
 gram shows the rawing of 
 the edges of the tear, and 
 the method of passing the 
 sutures. 
 
 
444 
 
 AFFECT'ONS OF THE UTERUS. 
 
 and its walls are brought together by sutures passed from 
 before backwards, so that the resulting line of incision 
 remains transverse. 
 
 In cases where there is considerable hypertrophy of the 
 cervix or of the whole uterus, or where marked endocervicitis 
 exists, it is best to curette the uterus, and to amputate the 
 cervix by the flap method, instead of attempting to repair 
 the laceration. 
 
CHAPTER XV. 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 Under this heading are considered alterations in the shape and 
 relation of the uterus in terms of version, flexion, and position. 
 Normally the uterus is anteposed, i.e. placed as a whole 
 in the anterior half of the pelvic cavity ; anteverted, i.e. with 
 its long axis so directed that the fundus looks towards the 
 front ; and anteflexed, i.e. with a slight bend in the long 
 axis of the uterus, the concavity being anterior. Normally 
 there may be a slight degree of lateriversion. 
 
 Occasionally we find a case of congenital retroposition, 
 i.e. the uterus as a whole is well back in the sacral hollow, 
 and anteflexed. More often thi;. condition is the result of 
 a posterior adhesive perimetritis. 
 
 I have already fully described the mobility in the uterus, 
 and the range of movement through which it is continually 
 passing. These must be kept in mind in the study of 
 displacements. 
 
 According to the ordinary descriptions, attention is drawn 
 to the four following forms of displacement : — 
 
 Anteversion. 
 
 Anteflexion. 
 
 Retroversion. 
 
 Retroflexion. 
 
 Anteversion. 
 
 It is absurd to refer to this as a special topic. Per se it 
 has absolutely no clinical importance, though for a long 
 
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446- 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 time this term has been used to describe a supposed special 
 diseased state of the uterus. 
 
 In this condition the uterus is enlarged, and the long axis 
 of the uterus more or less straightened, owing to the diminu- 
 tion of the normal slight anteflexion. The symptoms were 
 
 related to this altered condition of the 
 uterine axis. Such views must now be 
 considered as absolutely untenable. 
 They are incorrect. 
 
 There is no snecial disease of 
 anteversion. Nor does anteversion 
 produce any symptoms. Anteversion 
 is but one of the results of the thick- 
 FiG. IS4.— Metritis. The g^ing of the uterus, due to chronic 
 
 so-called ' ' anteversion" °. . — , . i i. ^ o 
 
 of the uterus is shown, metritis. Even m normal states the 
 
 uterus may often be found with very 
 little flexion. The treatment of anteversion is the treatment 
 of metritis. Special anteversion pessaries, such as Gehrung's, 
 Thomas', and Graily Hewitt's, were introduced when incorrect 
 ideas as to the pathology of the condition prevailed. They 
 were meant to lie in the vagina, and by 
 means of a projecting portion to press 
 through the anterior fornix against the 
 uterus, whose wall would thereby become 
 bent over it. It was also believed that the 
 pressure of the body would thus be taken 
 off" the bladder. 
 
 Now we know that no special influence 
 can be brought to bear on the corpus uteri 
 through the anterior fornix by such instru- ^'^- iSS— Thomas' 
 ments. Even if a slight flexion were pro- 
 duced (probably it could not be brought 
 about), the relation of the uterus to the bladder, and to the 
 rest of the pelvic floor, would remain the same, as far as 
 intra-abdominal pressure is concerned. 
 
 Such instruments must be abandoned. As I have already 
 
 anteversion 
 sary. 
 
 pes- 
 
 \ 
 
 I 
 
ANTEFLEXION. 
 
 447 
 
 .'/ ■.,•;. 
 
 *vir 
 
 Stated, the treatment is that of metritis. Sometimes in 
 this condition it may be helpful to support the uterus for 
 a time in order to relieve congestion where it is much en- 
 larged, an:' tends to drag down. This support may be given 
 by the use of vaginal glycerin plugs, which help to relieve 
 the congestion, as well, in another way. 
 
 But a ring or Hodge pessary may be used for this purpose 
 • — without any reference, however, to the so-called anteverted 
 condition of the uterus. 
 
 \ 
 
 Anteflexion. 
 
 This term is used to refer to an exaggeration of the 
 normal flexion on the uterus. It is impossible to say what 
 is a pathological angle of flexion. All degrees may be found 
 in conditions of perfect health. 
 In some cases the most extreme 
 anteflexion may be a congenital 
 condition, the uterus being often 
 undersized and having a long 
 conical cervix. 
 
 Acquired anteflexion is mostly 
 due to a posterior or utero-sacral 
 cellulitis, sometimes to a pos- 
 terior perimetritis. Owing to the 
 contraction of the inflamed bands 
 the cervix is drawn backwards 
 and somewhat upwards, the 
 fundus being lowered. Intra- 
 abdominal pressure fends to press 
 
 it continually downwc*rds, increasing the anterior flexion on 
 the uterus. Usually in these cases there is some degree 
 of inflammation in the uterine wall, which may lead to a 
 fixation of the organ with the extreme degree of anteflexion. 
 The point of flexion is usually at the isthmus ; sometimes it 
 is higher. 
 
 Fig. 156.— -Patholof^ical ante- 
 flexion of the uterus. The 
 cervix is drawn back by pos- 
 terior perimetritis and utero- 
 sacral cellulitis. 
 
V 
 
 448 
 
 DISPLACEMENTS OF THE UTERUS, 
 
 This condition is more common in nulliparous than in 
 multiparous women i^ide " Pelvic Cellulitis "). 
 
 Symptoms. — In many cases in which there is an abnormal 
 degree of flexion in the uterus there are no symptoms. It 
 is probably only to pathological accompaniments of the 
 anteflexion that we must look for the distressing symptoms 
 which are found in other cases. These are inflammation in 
 the uterine wall, in the peritoneum or cellular tissue behind 
 the uterus, or in the appendages ; or to an associated 
 marked stenosis of the cervical canal. The common 
 symptoms in these cases are leucorrhoea, sterility, dysmen- 
 orrhoea, dyspareunia. Menorrhagia, irregular menstruation, 
 or some degree of amenorrhoea may be present. There 
 may be frequency of micturition or pain on defaecation. 
 There may be reflex pains, e.g. under the left breast. 
 Neurotic phenomena may develop. (An explanation of the 
 causation of dysmenorrhcea in these cases is given in the 
 article on "Dysmenorrhcea," p. 129.) 
 
 Physical signs. — On bimanual examination the fundus 
 is felt easily through the anterior fornix, and the angle of 
 flexion can be readily distinguished. The cervix looks 
 downwards and forwards. So marked is the flexion that 
 it may be impossible to pass a sound without pulling the 
 cervix down with a volsella. 
 
 In some cases it is possible to straighten the uterine axis 
 between the fingers, but oftentimes this cannot- be done, so 
 rigid is the wall ; and attempts may cause the patient pain. 
 
 The condition of utero-sacral cellulitis or posterior 
 peritonitis may be made out best by a finger passed into 
 the rectum. 
 
 Differential diagnosis. — The condition is apt to be 
 mistaken for — 
 
 A small myoma in the anterior uterine wall. ^ 
 
 A cellulitic deposit between the cervix and bladder. 
 
 A tumour of the bladder wall or a vesical calculus. 
 
 In the first of these conditions the use of a sound along 
 
 i>. 
 
RETROVERSION AND RETROFLEXION 
 
 449 
 
 with the bimanual examination establishes the nature of the 
 case. The latter two conditions are rare. 
 
 Treatment. — The treatment of anteflexion is really that of 
 the various associated inflammatory conditions. Schultze 
 has pointed out how often cases improve as the inflam- 
 matory products are absorbed, even though the flexion of 
 the uterus may remain the same. 
 
 For a long time uterine stem pessaries have been used for the 
 purpose of straightening the uterus. Their use is based upon 
 a wrong understanding of the pathology, and they are dangerous 
 because of the injury they may cause to the uterine mucosa, 
 and because they may lead to septic infection. All forms of 
 this instrument should be abolished, whether simple firm 
 stems like Amann's, soft rubber stems like Greenhalgh's, or 
 firm stems combined with vaginal pessaries like Beigel's. 
 
 In cases in which the uterus is much enlarged from 
 inflammation, support of the organ for a time by means of 
 vaginal plugs, Hodge or ring pessaries, may be beneficial. 
 Their use has, however, nothing whatever to do with the 
 presence or absence of anteflexion. 
 
 Where stenosis of the cervix exists, dilatation should be 
 carried out. 
 
 Retroversion and Retroflexion. 
 
 Retroversion is the condition in which the long axis of 
 the uterus is directed so that the fundus looks towards the 
 back. Retroflexion is the condition in which the uterus is 
 bent, so that the concavity is directed towards the back ; it 
 is more commonly met with than the former. 
 
 As retroflexion is practically only found in a retroverted 
 uterus the two conditions may be considered together.^ 
 
 Etiology. — Temporary retroversion is brought about when 
 the bladder is over-distended. 
 
 Permanent retroversion and retroflexion occur in the 
 following conditions : — 
 
 29 
 
 "^Vide p. 27. 
 
m 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 \ 
 more 
 
 Fig. 157. — Retroversion of 
 the uterus. 
 
 1. They may be congenital, the former being 
 common than retroflexion. ^ . . ■«, . \ 
 
 2. They may occur in the puerperium. 
 
 The frequent occurrence of these displacements in this 
 period is due to the weight of the uterus causing the fundus 
 
 to gravitate towards the sacrum, 
 when the patient lies in the dorsal 
 position, the ligaments being in 
 a lax state. "Usually the con- 
 dition is only a temporary one, 
 the organ returning to the nor- 
 mal position as involution pro- 
 ceeds. 
 
 If, however, metritis develops 
 in the puerperium, if the patient 
 rises too soon or goes to 
 work too early, a permanent 
 displacement may be established. 
 
 3. They may be produced by posterior adhesions due to 
 peritonitis. 
 
 4. They may be caused by a small fibroid in the upper 
 part of the posterior wall of the 
 uterus. 
 
 5. They may be caused by a 
 sudden strain or fall. 
 
 6. They may be caused by 
 cicatrisation in the anterior 
 vaginal wall. 
 
 7. Retroversion is usually one 
 of the stages in the development 
 of a prolapsus uteri. 
 
 , Anatomical changes. — In 
 pure retroversion the fundus lies 
 in the hollow of the sacrum. The os is directed forwards. 
 The cervix presses against the bladder, and may be close to 
 the pubes if the uterus be much enlarged by metritis. 
 
 Fig. 158. — Retroflexion of 
 the uterus. 
 
RETROVERSION AND RETROFLEXION. 
 
 451 
 
 In retroflexion the fundus lies in the pouch of Douglas 
 varying in level according to the acuteness of the angle of 
 flexion, and to the extent to which the uterus as a whole is 
 prolapsed. • 
 
 According to many authorities the posterior wall is some- 
 what thinned at the angle of flexion, though in a congenital 
 case Ruge found the anterior wall atrophied at this point. 
 
 The whole organ is usually congested and somewhat 
 enlarged. Metritis is very often present in it. In some 
 cases, however, these conditions do not exist. 
 
 The OS externum 
 looks forwards and 
 downwards, some- 
 times forwards only, 
 sometimes down- 
 wards. It may, there- 
 fore, in some cases be 
 found close to the 
 pubes. 
 
 As a result of these 
 posterior displace- 
 ments, the ovaries 
 and tubes are dragged 
 downwards, often to 
 an unequal extent. 
 Sometimes they may 
 lie below the uterus in 
 the pouch of Douglas. 
 
 The bladder may not be altered in position, but some- 
 times it is tilted somewhat forwards. Intestines lie on it, 
 and on the anterior surface of the uterus. 
 
 The ureters may be compressed or bent, leading to 
 dilatation. This may lead to changes in the kidneys. 
 
 The rectum may be considerably pressed upon. 
 
 The utero-sacral ligaments get stretched. The broad 
 ligaments are bent on themselves. 
 
 Fig. 159. — ^Vertical mesial section of the 
 pelvis of a wo^an who died on the fifteentl 
 day of the puerperium. The uterus is 
 retroflexed. 
 
\, 
 
 4S« 
 
 DISPLACEMENTS OF THE UTERUS, 
 
 
 
 Various inflammatory changes may be found associated 
 with these displacements, e.g. metritis, endometritis, endocer- 
 vicitis, ovaritis, salpingitis, peritonitis. Owing to the forma- 
 tion of adhesions, the displaced uterus may be more or 
 less fixed. 
 
 In most cases these inflammations are independent of the 
 displacement. Whether the latter condition can aggravate 
 these inflammatory processes is doubted by many. Accord- 
 ing to others, it can in a marked retroflexion, owing to the 
 sluggishness of the uterine circulation, and to congestion as 
 a result of the bending of the vessels in the broad ligament. 
 The venous network is so rich, however, that it is difficult 
 to understand how this can be brought about. At any rate, 
 the clinical fact is established, that in these posterior displace- 
 ments profuse menstruation is common ; and even though 
 we attribute this phenomenon to the inflammatory chaiiges 
 in the uterus, it must be admitted that they are in some way 
 affected, especially by a marked retroflexion. There is no 
 proof, however, that a simple posterior displacement, unac- 
 companied by inflammation, is necessarily followed by this 
 complication. Indeed, it is hard to understand why this 
 should be so, if we believe that practically all uterine 
 inflammations are of infective origin. It may be suggested, 
 though it is not proved, that the displacement may somehow 
 alter the state of the uterus, so as to render it more liable to 
 infection by microbial action. 
 
 Physical signs. — On bimanual examination the retroverted 
 uterus is felt, the body being made out through the posterior 
 fornix. Per rectum the fundus may usually be easily felt. 
 In retroflexion the rounded body is felt in the pouch 
 of Douglas, an angle being made out between it and 
 the cervix. When one is moved the other usually moves 
 also, unless fixed by adhesions. In both conditions the 
 fingers may meet in front of the cervix, the uterine body not 
 being found in its normal position. Sometimes, to feel the 
 fundus easily, it may be necessary to pull down the cervix 
 
 /•r 
 
 ( 
 
 ? > 
 
RETROVERSION AND RETROFLEXION. 
 
 453 
 
 with a volsella. On passing a sound, its concavity looks to 
 the back. It is important to note that this instrument is only 
 used as a confirmatory test. It is never to be employed at 
 first to determine the existence of a displacement. 
 
 Students must be particular not to trust to the mere 
 vaginal examination, for the position of the cervix is no sure 
 indication of the relations of the corpus uteri. • . 
 
 Symptoms. — In some cases no symptoms whatever are 
 found. Often one or more of the following symptoms 
 may be associated with these posterior displacements : a 
 bearing-down feeling, weakness or pain in the back ; weak- 
 ness or pains in the lower limbs ; constipation, with or 
 without tenesmus j frequency or difficulty in micturition ; 
 menorrhagia, dysmenorrhoea, leucorrhcea, tendency to abor- 
 tion, sterility. Reflex and neurotic phenomena are often 
 found. 
 
 There is some difference of opinion as to the part played 
 by a backward displacement of the uterus in the causation 
 of symptoms, which are so often found accompanying the 
 condition. Some hold that retroversion per se does not 
 produce troublesome symptoms ; they state that normally 
 the uterus is constantly changing its position, according to 
 changes in the condition of bladder and bowel, and that 
 it may, when turned to the back, trouble the woman as 
 little as when turned to the front. They state that the 
 symptoms which are so often found along with retroversion 
 — e.g. pain and weakness in the back, menorrhagia, etc. — are 
 due to accompanying pathological conditions, namely, in- 
 flammations outside the uterus, inflammations in the uterus 
 itself, subinvolution, or some prolapse of the organ. 
 
 In favour of these opinions may be mentioned the fact 
 that cases are found in which, along with a retroverted 
 uterus, no symptoms whatever are found. Moreover, the 
 forward position of the uterus, as a whole, does not seem 
 necessary to health, because, in certain cases, retroposition 
 of the uterus may exist along with perfect health. ■ i 
 
454 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 Other authorities hold that the backward displacement 
 per se may lead to bad symptoms. 
 
 I have already (p. 452) referred somewhat to the relation 
 of posterior displacements to the various conditions often 
 associated with them, and it is needless further to consider 
 the different views which are held. I would point out, 
 however, that the above symptoms are those which we find 
 with the various inflammatory conditions which occur in the 
 pelvis. No doubt influence cf retro-displacements per se, in 
 causing symptoms, has been greatly exaggerated. 
 
 Differential diagnosis. — The following conditions must 
 be diagnosed from retro-displacements : — 
 
 1. Masses of faeces in the rectum. 
 
 2. Utero-sacro cellulitis ; peri-rectal deposits. 
 
 3. Deposits in the pouch of Douglas, e.g. haematocele; 
 peritonitis. "^ " 
 
 4. Prolapsed ovarian or tubal swellings. ' ' ' 
 
 5. Myoma of posterior uterine wall. 
 
 Treatment. — It is of the utmost importance to treat 
 inflammatory conditions associated with the displacement. 
 In some cases it is well to replace the uterus, and to intro- 
 duce a vaginal pessary. The following varieties of conditions 
 are met with : — 
 
 1. Retroversion accompanied with fixation by means of 
 peritonitic adhesions. 
 
 In such cases the uterus cannot be replaced, i.e. turned 
 to the front. Pessary treatment is of no avail. The case 
 must be treated by douches, baths, electricity, glycerin 
 plugs. Stretching of adhesions by means of massage or by 
 means of vaginal dilators — e.g. Bozeman's — is recommended 
 by some. (Other recommendations as regards operative 
 interference I will consider afterwards, vide p. 458.) 
 
 2. Retroversion of a freely movable uterus, not enlarged, 
 unaccompanied by pelvic trouble. 
 
 In such cases there seems to be no necessity, as a rule, 
 for the replacement of the uterus and the introduction of a 
 
RETROVERSION AND RETROFLEXION. 
 
 455 
 
 (' 
 
 pessary. When, however, women in such a condition are 
 liable to the strain of heavy lifting, or to chronic bronchitis, 
 it may be considered advisable to use a pessary for the pur- 
 pose of keeping the uterus anteverted. For undoubtedly 
 the uterus may, when retroverted, show a greater tendency 
 towards prolapsus under the influence of increased intra- 
 abdominal pressure than when it is anteverted. In these 
 cases the Hodge or Albert Smith pessary does well. 
 
 3. Retroversion of the freely movable puerperal uterus, 
 unaccompanied by pelvic troubles. 
 
 It is now recognised that normally, in many women, dur- 
 ing the involution of the uterus in the early weeks after 
 labour, the uterus may be turned to the back. 
 
 When, in such cases, good health exists, no pessary treat- 
 ment is necessary, unless it is known that the patient has 
 suffered previous to her pregnancy, in early pregnancy, or 
 unless she is subject to strains which increase the intra- 
 abdominal pressure. , 
 
 The Hodge or A'bert Smith pessary may be used in these 
 cases. 
 
 4. Ret'*oversion of the movable pregnant uterus in the 
 early monihs. In every case the uterus should be replaced, 
 and a pessary worn until the pregnancy has well entered the 
 fourth month, i.e. until all danger of an incarceration in the 
 pelvis is past. 
 
 The Hodge or Albert Smith pessary may be used. 
 
 5. Retroversion of a movable uterus, where pelvic symp- 
 toms are present, but where the ovaries are not prolapsed 
 into the pouch of Douglas, nor any special tenderness exists 
 in the perimetric or parametric tissues. 
 
 In such a case the uterus should be replaced, and a Hodge 
 or Albert Smith pessary introduced. 
 
 5. Retroversion of a movable uterus whce pelvic symp- 
 toms are present, and where one or both of the ovaries are 
 prolapsed into the pouch of Douglas. 
 
 These are generally very troublesome cases to deal with. 
 
V, 
 
 456 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 ! 
 
 If the ovaries be inflamed as well as prolapsed, no pessaries 
 should be used until glycerin plugs and the vaginal douche 
 have been used. After the uterus is replaced it is often a 
 matter of difficulty to select a pessary. In a certain number 
 of cases owing to the sensitiveness of the ovaries no form 
 of instrument can be worn. In other cases a Hodge or 
 Albert Smith pessary acts well and causes no pain even 
 though the ovaries remain prolapsed. A Thomas pessary 
 with a thick soft rubber upper end may often be more 
 suitable than entirely hard instruments, or a soft rubber 
 ring pessary may often be borne when no hard instrument 
 can be tolerated. In all cases where the ovaries are notice- 
 ably tender or inflamed, it is best, after the use of the 
 douche and plugs, to use a ring pessary for a time before 
 trying one of the hard instruments. Though the ring 
 may not keep the uterus to the front, merely acting 
 as a general support to the uterus, it has a beneficial 
 influence in allowing congestion of the uterus to be 
 relieved. 
 
 In some cases of prolapse of one ovaiy only, benefit may 
 be obtained from the use of a hard instrument, in which the 
 upper angle on one side is absent to ensure non-pressure on 
 the ovary, while the pessary is in position. / 
 
 7. Retroversion of a movable uterus, accompanied by 
 pelvic symptoms, where old posterior perimetritis or some 
 remains of cellulitis are present. 
 
 These cases are also very troublesome. The line of 
 treatment as regards pessaries is the same as that laid down 
 in the last section. 
 
 Betroflexion of the uterus. — All that has been said re- 
 garding the use of pessaries in the treatment of retroversion 
 may be stated with regard to retroflexion. Practically, 
 wherever retroflexion exists retroversion is present, and the 
 employment of pessaries like Hodge's and Albert Smith's, 
 after the replacement of the uterus, is related primarily to 
 the posterior version, not to the flexion. Disappearance of 
 
 
METHODS OF REPLACING THE UTERUS. 
 
 457 
 
 
 the flexion depends on the consistence of the uterus and 
 its relation to the intra-abdominal pressure. 
 
 In some cases, after a pessary has been worn for some 
 months, the uterus shows no tendency to return to the 
 displaced position. In other cases, the instrument must be 
 continually worn to keep the uterus to the front. 
 
 Methods of Replacing the Uterus. 
 
 1. By the abdomino-recto- vaginal bjuiianual examina- 
 tion. — Sometimes this may be employed satisfactorily, when 
 
 
 Fig. i6o. — Diagram showing right and wrong methods of 
 
 rotating the sound,— After Hart and Barbour. 
 
 1. Right method, long rotation of handle. 2. Wrong method. 
 
 the patient lies in the dorsal position, the abdominal walls 
 being thin and lax. Or it may be done with the patient in 
 the Sims' position. 
 
 2. By the genu-pectoral posture. — The patient is placed 
 in this position, and the vagina opened to allow air to enter. 
 The displaced uterus tends to fall towards the sacrum, and 
 if the cervix be tilted towards the sacrum by a finger passed 
 into the vagina, the fundus may pass downwards and for- 
 wards to the front. Sometimes it is necessary to use recto- 
 vaginal manipulations to cause the fundus to move from the 
 
V 
 
 458 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 back. (In carrying out this procedure the patient's clothes 
 must be loose.) 
 
 Sometimes it is advantageous to pull down the cervix 
 with a volsella. 
 
 3. With the sound. — Having made out the position of 
 the utfus and the absence of adhesions, the sound is passed 
 as described on p. 199, the patient lying on her left side 
 with her legs drawn up. The handle is then carried upward 
 towards the patient's right buttock, and forward and down- 
 ward with a long sweep until it lies over the symphysis. 
 The handle is then slowly and gradually carried back 
 towards the perineum. 
 
 By this manoeuvre, the fundus uteri is readily carried to 
 the front. 
 
 In cases of retroversion with adhesions, Schultze has 
 recommended the bimanual tearing of adhesions, under 
 anaesthesia. This method is not to be recommended, on 
 account of the dangers associated with it, e.g. tearing into 
 vessels, bowel, dilated tubes, etc. 
 
 Operative Measures. 
 
 Within recent years there has been an enormous amount 
 of ingenuity displayed in devising operations for the purpose 
 of replacing the uterus, and keeping it permanently to the 
 front. Too strong a protest cannot be urged against the 
 wholesale manner in which these procedures have been 
 carried oul. It must be clearly understood that the indica- 
 tion for operative interference is not to be the mere fact 
 that the fundus uteri is turned toivards the back. I hold 
 that the great majority of cases can be satisfactorily treated 
 by measures taken to check the very inflammatory processes 
 which may be found, and by the judicious use of pessaries. 
 
 If we believe that the displacement per se does not cause 
 the symptoms, it is surely bad logic to make the replace- 
 ment of the uterus the main element in our therapeutic 
 
 f \ 
 
OPERATIVE MEASURES. 
 
 459 
 
 procedures. Mor*^over, it is surely contra naturam to turn 
 the uterus to the front, and to fix it there. 
 
 Then, these operations have been recklessly carried out 
 without regard to the effect on after-pregnancies. We are 
 just now beginning to gather facts regarding their influence 
 in causing miscarriage, and in introducing difficulties into 
 labour. 
 
 At the present time, therefore, it is impossible accurately 
 to lay down the indications for operative treatment in cases 
 of retro-displacements. 
 
 If the patient has no symptoms, certainly there is no 
 necessity for operative measures. All the simpler measures 
 must be first of all carefully employed. 
 
 Only a few cases are left in which little or no improvement 
 may be gained by these means. 
 
 This residuum must be carefully studied to eliminate 
 neurotic complications and disease in the appendages. 
 
 There exists, then, only a small number of cases in which 
 operative measures should be carried out. The following are 
 on their trial : — 
 
 I. Shortening the round ligaments (Alqni^- Alexander- 
 Adams operation). — Various methods are used. The follow- 
 ing by Edebohls may be employed. 
 
 An incision of 2 in. long is made through skin, fat, and 
 aponeurosis of the external oblique muscle, from the pubic 
 spine upward and outward, parallel with the inguinal canal, 
 exposing the canal from the external to the internal ring, as 
 well as the internal oblique muscle and round ligament. 
 The ligament is more or less concealed, according to the 
 greater or less development of the internal oblique. Some- 
 times it is found with difficulty, or not at all. The ligament 
 is then freed from its attachments in the canal and drawn 
 outwards, the investing peritoneum of the broad ligaments 
 being stripped backward. 
 
 A deep continuous catgut suture is then passed, embracing 
 the internal oblique, transversalis, Poupart's ligament, and 
 
V. 
 
 460 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 transfixing the round ligar^ent ; the uppermost loop fastens 
 the margins of the internal ring. A superficial continuous 
 suture is then passed through the aponeurosis of the external 
 oblique to restore the anterior wall of the canal, the excess 
 of round ligament outside the external ring having been cut 
 away ; the lower end of the ligament is transfixed by the 
 lower part of the latter suture. Then the skin and fat are 
 closed by a superficial suture. 
 
 Complications due to adhesions. — According to some 
 operators it is unwise to attempt this operation when pelvic 
 adhesions exist. According to Edebohls and others the 
 adhesions may be first of all broken down, either by means 
 of a colpotomy, a median cceliotomy, or an incision through 
 the peritoneum at the internal ring. 
 
 ■ ' After-treatment. — The wound is dressed in the ordinary 
 manner. The patient is kept in bed for a month, a Hodge 
 or Albert Smith pessary being worn during this time and 
 after she rises for a few months, in order to support the 
 uterus while healing and consolidation take place. 
 
 Value of this operation. — According to Pozzi, the greatest 
 
 benefit is obtained in old cases where there is some prolapse, 
 
 and where there has been such extensive injury of the pelvic 
 
 floor as to render local repair measures impossible (such 
 
 cases are extremely few — J. C. W.) ; also in cases where the 
 
 ovaries are prolapsed, thus preventing a pessary from being 
 worn. 
 
 2. Ventro - fixation (gastro - hysteropexia). — Various 
 methods have been employed. That of Kelly, who intro- 
 duced the operation, may be recommended. f'- 
 
 The patient is placed in the dorsal position, with hips 
 elevated. The abdominal cavity is opened by the median 
 incision (i^ to 2 in. long) above the symphysis. Two 
 fingers are introduced, and the fundus of the uterus raised 
 to the incision. A silk suture is then passed through the 
 cut edges of the peritoneum and posterior surface of the 
 corpus uteri, about ^ or f in. from the lower end of the 
 
OPERATIVE MEASURES. 
 
 461 
 
 incision. This is firmly tied. Another is passed higher up, 
 passing through the posterior uterine wall, about \ in. below 
 the other, and firmly tied. 
 
 The peritoneal edges are then closed with catgut, and the 
 rest of the incision sutured. 
 
 Sometimes in this operation it may be difficult to raise 
 the fundus. Usually it is best to support it by two fingers 
 placed against the symphysis, while the first suture is being 
 passed. If this cannot be done, an elevator may be used to 
 hold up the fundus. 
 
 4fter-treatment — The patient is kept in bed for three 
 weeks. Afterwards she must take only gentle exercise for 
 weeks, and should do no heavy work for six months. The 
 bowels and bladder should be emptied with strict regularity. 
 
 Value of this operation. — Kelly has had no hcnia after 
 this operation, nor any serious trouble with the bladder. 
 
 Very few relapses occurred. He followed the history of 
 fourteen cases in which labour took place at a later period, 
 and found trouble due to the adhesions of the uterus only 
 in one. In most cases the uterus does not remain close to 
 the abdominal wall, but is suspended from it by two or 
 more adhesions, so that the organ has a certain range of 
 movement. It might be expected that these would be a 
 source of danger to the bowel. 
 
 Where there is a torn perineum and some degree of 
 prolapsus, it is best to follow the suspensory operation by 
 one for the repair of the damaged parts. If this be not 
 done, the suspensory operation alone, according to Kelly, is 
 of no use, as relapse will occur. " 
 
 3. Vesico-fixation and ventro-vesico-fixation. — Werth 
 recommends these instead of simple ventro-fixation, because, 
 after the latter operation, a space is left between uterus and 
 bladder in which bowel may be incarcerated. Such a risk, 
 he says, does not exist if the anterior surface of the uterus be 
 stitched to the bladder, or if this, as well as ventro-fixation 
 be performed. . . • • . - 
 
V 
 
 462 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 4. Vaginal fixation. — Instead of the peritoneal cavity 
 being opened, the anterior vaginal wall is divided in its upper 
 three-fourths. The base of the bladder is separated from it 
 and from the cervix. The peritoneal reflection from bladder 
 to uterus is stripped upwards as high as possible, the cervix 
 being pulled downwards with a volsella. The cervix is then 
 pushed well back and catgut sutures (No. 3) passed through 
 the edges of the vaginal incision, the cellular tissue between 
 cervix and bladder, and the surface of the uterus below the 
 peritoneum. 
 
 The remaining united edges of the vaginal wound are 
 then closed with continuous catgut. 
 
 Vesico-fixation, ventro-vesico-fixation and vaginal-fixation 
 are not to be employed, if the patient runs any risk of falling 
 pregnant after the operation. The uterus is kept to the 
 front certainly, but the danger of miscarriage and the risks 
 of great difficulties in labour are too serious to warrant the 
 employment of the operation in the reproductive era of a 
 woman's life. 
 
 5. *ryor's operation,— This method is on its trial; recently 
 its orij. nator has reported two cases where it was followed 
 by normal pregnancy and labour. 
 
 The pouch of Douglas is opened per vaginam. Adhesions 
 in it are broken up with the fingers. An iodoform gauze pad 
 is placed in the pelvis behind the cervix, and the patient 
 put in the Trendelenburg position. The intestines gravitate 
 towards the diaphragm, and a second pad is placed in the 
 pelvis. The table is then placed horizontally. The pads are 
 withdrawn, and a wad of gauze placed in the vaginal open- 
 ing, reaching just within the incision. The uterus is now 
 anteverted by bimanual manipulation. 
 
 After-treatment. — The gauze is removed in seven or ten 
 days, and replaced, the patient being chloroformed. This is 
 changed in a week, and again in five days. The vagina is 
 packed all the time. 
 
 By this operation x dense mass of lymph is produced 
 
 f \ 
 
RETROPOSITION- — INVERSION. 
 
 463 
 
 behind the cervix, which, on organisation and contraction, 
 pulls it towards the back, the fundus being left freely 
 movable. 
 
 Retroposition of the Uterus. 
 
 This condition may be congenital. Tumours may some- 
 times press the uterus backward as a whole. It may be due 
 to inflammatory adhesions behind the uterus, and may 
 follow a retro-uterine haematocele. 
 
 There may be no symptoms, or symptoms may be caused 
 by the inflammatory conditions, 
 and by the backward traction 
 on the bladder. The condition 
 is treated as is retroversion. 
 
 Inversion of the Uterus. 
 
 This is the condition in which 
 the organ is turned in upon 
 itself, the inverting portion 
 extending downwards towards 
 or through the cervix. 
 
 Etiology. — Inversion occurs under two conditions — (i) In 
 the puerperal state; (2) associated with the growth of a 
 tumour in the uterine wall. 
 
 I. Inversion is caused in the puerperium in the following 
 ways : — - 
 
 (a) Traction on the cord, the uterus being non-retracted 
 and uncontracted. 
 
 {b) Sometimes it appears that that part of the wall to 
 which the placenta is attached is somewhat paralysed, and 
 unable to retract and contract like the rest of the wall. As 
 contractions take place in the surrounding musculature, the 
 placental portion, being inert, may be depressed towards the 
 cavity of the uterus, intra-abdominal pressure then continu- 
 
 FiG. 161. — Retroposition of 
 the uterus. 
 

 464 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 ing to aid the further inversion of the part. This process is 
 usually brought about slowly. 
 
 2. In the case of tumour growth, e.g. malignant infiltra- 
 tion of the upper part of the corpus uteri, inversion may be 
 brought about as a result of the weakening of that portion 
 which is affected, and which becomes pressed in towards the 
 cavity. The same thing may be produced by a tumour 
 becoming polypoidal in the cavity, e.g. fibromyoma. 
 
 Pathology. — In the suddenly produced inversion of the 
 puerperium, the inverted portion may lie in the vagina or 
 partly protrude through the vulva. It may be smooth, 
 
 covered by the placenta and 
 membranes, or raw, red, soft, 
 and bleeding. 
 
 In the more slowly produced 
 condition, various stages are 
 found. A cup-shaped depres- 
 sion is formed on the peritoneal 
 surface where the inversion 
 takes place. In old cases the 
 mouth of the cup usually be- 
 comes a slit. 
 
 The inverting portion, gener- 
 ally the fundus, may extend as far as the cervix, or through it. 
 The cervix may be loosely felt around the inverting mass, or 
 may form a tight constriction. Sometimes the cervix may be 
 partly inverted, but its complete inversion never occurs. The 
 vagina may become inverted. When the inverted uterus lies 
 in the vagina, it may look like a fibroid polypus ; but it is, in 
 the early stages, of a deeper red, and softer, and bleeds easily 
 when handled. The mucosa may become much inflamed, 
 and may ulcerate or become gangrenous ; in some cases it 
 may take on the characters of the vaginal epithelial covering, 
 losing its glands, and becoming hard. 
 
 The ovaries and tubes, and even intestines, may lie in 
 the cup-shaped depression on the peritoneal surface. In 
 
 Fig. 162. — Partial inversion of 
 the uterus. 
 
INVERSION. 
 
 465 
 
 old cases they are usually withdrawn. Adhesions rarely 
 form between the peritoneal edges of the depression, which 
 may get very contracted. 
 
 If there be prolapse of the uterus as well as inversion, the 
 bladder is dragged downwards. 
 
 Ssrmptoms. — In the suddenly produced cases, the patient 
 feels as if something had given way ; there may be severe 
 pain, haemorrhage, collapse, retention of urine. Septicaemia 
 may result. 
 
 In chronic inversion there is menorrhagia, metrorrhagia, 
 leucorrhoea, bearing-down, and 
 other pains in the pelvis. The 
 patient may become run down 
 and anaemic. Reflex and neu- 
 rotic symptoms may develop. 
 
 Diagnosis. — Bimanually, in 
 advanced cases, a mass is felt 
 in the vagina, with the charac- 
 ters already described. It is 
 somewhat moulded by the 
 vaginal walls. The rim of the 
 cervix can usually be dis- 
 tinguished, and the finger may 
 be passed up around the in- 
 verting portion for a distance 
 in some cases. Sometimes this 
 is impossible, owing to the con- 
 traction of the cervix, or to adhesions between it and the 
 inverting mass. If the inversion has not passed the cervix, 
 the finger may be passed into the cavity and distinguish the 
 condition. The outer hand feels the cup-shaped depression 
 through the abdomen, and recognises that the fundus is 
 absent. 
 
 The condition must be diagnosed from — 
 
 1. In^^ra-uterine polypus. 
 
 2. Polypus extending into vagina. 
 30 
 
 Fig. 163. — Complete inversion 
 of the uterus. The latter has 
 a fibroid tumour attached at 
 the fundus. 
 
466 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 3. Polypus with inversion. 
 
 4. Prolapsus uteri. 
 
 5. Inversion with prolapsus uteri. 
 
 Eesults. — Sometimes spontaneous cure may result. The 
 patient may die sometimes in acute cases from shock, 
 haemorrhage^ etc. A chronic condition of ill-health may 
 develop. Sometimes, in old chronic cases, patients may 
 not complain much. 
 
 Treatment. — Recent. — If a case be seen soon after in- 
 version has occurred, it may be possible to undo the 
 inversion and to replace the uterus at once. The patient, 
 anaesthetised, is put in the lithotomy position, the genital 
 tract being carefully washed with antiseptic solution. The 
 rectum and bladder should be emptied, and bimanual 
 reposition should be attempted. One hand is placed on 
 the lower abdominal region, while the other grasps the mass 
 of the uterus, pushing it up and undoing the inversion. 
 Sometimes it is best to dimple inwards one part of the wall, 
 making the rest follow. If there be a tumour attached to 
 the wall which can be removed, its base should be ligatured, 
 and the mass cut away. It may be safest to do this when 
 the uterus is replaced. 
 
 After replacement the uterus is douched with a hot 
 antiseptic solution. The cavity is then packed with 
 iodoform gauze, as well as the vagina, and the patient put 
 to bed. 
 
 After-treatment. — In two days the plug is removed, a 
 daily hot uterine douche is given, ergoc being administered 
 by the mouth. The patient lies in bed, according to the 
 nature of the condition. If it is a puerperal case, for twelve 
 or fourteen days ; if not, about eight days. If a tumour has 
 been removed, for two or three weeks. 
 
 Chronic. — Previous to the attempt to replace the uterus 
 the patient should be kept at rest in bed for a few days, the 
 bowels being moved regularly. If the inverted uterus does 
 not extend outside the vulva, a Barnes bag should be 
 
INVERSION. 
 
 467 
 
 distended in the vagina each day. This may cause the 
 uterus to be replaced. But if not, it causes the vagina to 
 be stretched so that there is more room for the manipu- 
 lations required. The night before the operation a dose of 
 opening medicine should be administered, and the next 
 morning an enema should be given, the rectum being after- 
 wards washed out with boracic lotion. Morphine should 
 be given. The patient is anaesthetised and placed in the 
 lithotomy position. The vagina is well lubricated with 
 antiseptic vaseline, and the bimanual manipulations a'ready 
 described are attempted. Sometimes, by pressing a fore- 
 finger into the rectum, the uterus may be steadied and 
 counter-pressure may be made. Some, in addition, advise 
 passage of the other forefinger into the bladder. 
 
 When the hand gets tired of pressing up the fundus, 
 continuous pressure may be exerted on it by means of 
 a cup and stem attached to a spiral, which is pressed 
 against the operator's chest. It may be necessary to pull 
 the cervix d(jwn with a volsella, and sometimes incisions 
 into it are necessary. - 
 
 If partial reposition can only be obtained at one sitting, 
 the patient should be put to bed, a Barnes bag being placed 
 in the vagina. Opium should be given. 
 
 When manual manipulations fail to replace the uterus, 
 continuous slight elastic pressure may be kept up by means 
 of a cup and curved stem attached to elastic bands, which 
 are fastened to an abdominal belt. A pad soaked in 
 antiseptic vaseline is placed in the cup, which is made to 
 press against the inverted fundus, in the line of the axis of 
 the uterus. Counter-pressure is kept up by means of a pad 
 placed above the pubes, and held in position with an 
 abdominal band. 
 
 If all methods fail to bring about replacement, the 
 question of removal of the uterus must be considered. If 
 malignant disease, bad ulceration, or gangrene exists in the 
 wall, amputation or extirpation should be performed. In 
 
V 
 
 4a 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 either case, the most thorough disinfection of the uterus 
 and vagina should be made. 
 
 Amputation. — The patient is placed in the lithotomy 
 position. The inverted fundus is steadied with a volsella. 
 Carefully determine the natural neck of the inverted portion. 
 Pierce the neck with a pedicle needle carrying a strong 
 double silk ligature. Withdraw the needle. Divide the 
 ligature into two equal parts. Ip*^erlace them and embrace 
 the neck, tying the ligatures on each side. 
 
 Fig. 164. — Replacement of inverted uterus by the aid of 
 
 White's repositor — Thomas. / 
 
 Then grasp the neck three-eighths of an inch below the 
 ligatures with two pairs of forceps, and cut off the uterus 
 below them. If there be any bleeding from the stupip, tie 
 the neck again with one of the ligatures already passed. 
 Then cut short the ligatures, remove the forceps, and place 
 an iodoform gauze plug in the vagina. This is removed 
 
 ( \ 
 
INVERSION. 
 
 469 
 
 in two days, and an antiseptic douche is afterwards given 
 daily. Ttiere is some risk that the stump may spring back 
 into the pelvis and the wound burst open. 
 
 Extirpation. — This should undoubtedly be performed if 
 sloughing, gangrene, or malignant disease exists in the 
 uterus. 
 
V 
 
 \ 
 
 V . .f. 
 t 
 
 CHAPTER XVI. X 
 
 FIBROMYOMA UTERI. 
 Myoma Uteri — Fibroid Tumour. 
 
 Pathology. — These turrours are composed of non-striped 
 muscle and fibrous tissue. They are much nore frequent 
 in the corpus uteri than in /the cervix, and are more 
 common in the posterior wall. According to one authority, 
 one-fifth of all women over 35 have these tumours. They 
 vary in number. There may be only one, or they may 
 be very numerous. They may grow to a great size — even 
 weighing as much as 140 lbs. 
 
 The fibrous and muscular elements vary greatly in their 
 proportions in different cases. Where the muscle is greatly 
 in excess, the tumour is of a somewhat soft consistence, 
 flesh-coloured, and usually without a very distinct complete 
 capsule; this form is known as soft myoma^ and is not 
 common. It is usually single. 
 
 The common fibromyoma is firm, pinkish grey in colour, 
 and is usually multiple. There is a distinct covering of 
 loose connective tissue, which, with the surrounding mus- 
 cular wall, forms a capsule. The tumour may be completely 
 surrounded by this connective tissue, or at one point its 
 substance may be continuous with the uterine wall, or it 
 may be connected by several bands. The capsule is very 
 vascular. 
 
 On section, the surface has a smooth shiny white appear-, 
 ance ; often it bulges out irregularly after being cut. Many 
 
PATHOLOGY. 
 
 471 
 
 Fig. 165. — Section through a 
 small fibromyoma, showing 
 the ' ' cotton-hall ' ' appearance of 
 the cut surface of the tumour. 
 
 These tend to contract 
 
 intercrossing bands of fibres are visible, and often the mus- 
 cular bands are arranged in whorls, surrounded with connec- 
 tive tissue — an appearance which has been compared to an 
 arrangement of cotton-balls. 
 Usually the tumour contains 
 few vessels. In some cases the 
 capillaries are dilated through- 
 out it, giving rise to an angio- 
 matous appearance — the 
 " teleangiectatic myoma " or 
 " myoma cavernosum." 
 
 In the capsule the large veins 
 often tend to gape on being 
 cut, because of their attachment 
 to surrounding muscular tissue. 
 The pedicles of pedunculated 
 tumours may contain large arteries, 
 and retract when cut across. 
 
 Nerves pass into the tumour; their endings have been 
 found in the muscular fibres. 
 
 On microscopic section, the muscle cells are fusiform in 
 
 shape, with elongated rod-shaped 
 nuclei; on transverse section, a 
 number present a kind of mosaic- 
 like appearance, which might be 
 mistaken for a collection of round, 
 niKleatedlcellSs Between t&e muscle- 
 bundles, connective tissue, poor in 
 cells, is arranged ; in some cases 
 it is found in bundles. 
 Fig. 166. -^Section through Fibromyomata grow slowly ; the 
 a portion of a myoma. i_ j ^ ^1 i ^1 
 
 more abundant the muscle the 
 
 more rapid the growth ; a soft myoma develops most 
 quickly. Progress is hastened by pregnancy. In the 
 puerperium they usually diminish in '••'.e again, and 
 sometimes shrijik up entirely. After the Climacteric, which 
 
w 
 
 V 
 
 47a 
 
 FIBROMYOMA UTERI. 
 
 15 
 
 is usually delayed in fibromyoma, their growth stops, and 
 shrinkage occurs ; rarely does growth continue after this 
 period. 
 
 Sometimes they may grow into neighbouring viscera, by 
 bringing about atrophy of their walls. 
 
 Certain changes may take place in these tumours : — 
 
 1. Softening may occur, and may be due to oedema, or 
 to myxomatous degeneration. Fatty degeneration is also 
 said to occur, but it is extremely rare. 
 
 2. Hardening usually occurs after the menopause. — It 
 is due to the contraction and fibrous change in the inter- 
 muscular connective tissue elements and to gradual dis- 
 appearance of the muscle. 
 
 3. Calcification occasionally occurs, due to deposits of 
 salts of lime, generally in the centre of the tumour, some- 
 times in the outer layers. A calcified tumour is termed a 
 " womb-stone." 
 
 4. Inflammation; suppuration; gangrene. — These pro- 
 cesses may follow an operation on the uterus ; they may 
 follow constriction of the vessels in the neck of a tumour as 
 it is being spontaneously enucleated ; they may follow in- 
 fection from an ulceration of the covering of submucous 
 polypoidal fibroid; they may follow torsion of a subperi- 
 toneal pedunculated tumour. 
 
 General septic poisoning may result, and the pus may 
 spread to surrounding tissues. A suppurating fibroid may 
 discharge itself through the uterine cavity, may perforate 
 the peritoneal surface of the uterus, or may open into the 
 bladder or bowel. ; 
 
 5. Sarcomatous change may occur in a fibroid. — Rarely 
 it is believed that carcinomatous changes may occur also (this 
 may possibly start from the mucosa or from remains of the 
 Wolffian body, according to Freund and Recklinghausen). 
 
 Changes in the uterus. — In the great majority of fibroids 
 there is a hyperplasia of the mucosa, considered by many 
 to be due to endometritis. Inflammatory changes are 
 
 
 \\ 
 
VARIETIES OF TUMOUR. 
 
 473 
 
 certainly often found in it. This may be interstitial, 
 glandular, or mixed; sometimes it is of the haemorrhagic 
 type. According to Wyder, the nearer the tumour is to 
 the mucosa the more the inflammatory changes are apt to 
 occur in the interglandular portion of the mucosa. 
 
 The uterus is enlarged as a whole. Its position may be 
 greatly altered. It may be drawn upward, pushed down- 
 ward to one side, or twisted on itself; it may become 
 inverted by a submucous fibroid. 
 
 Changes in other organs. — Sometimes inflammatory 
 changes are produced in the kidneys ; occasionally the 
 uterus may be pressed on, leading to their dilatation, along 
 with hydronephrosis, pyelitis, or pyelonephritis. Heart 
 lesions are sometimes found, e.g. hypertrophy, with or 
 without dilatation, or with degeneration of cardiac muscle ; 
 these may be due to a renal lesion in some cases. 
 
 Haematosalpinx is sometimes found, and in the ovaries 
 considerable changes are often seen. 
 
 V, 
 
 Varieties of Tumour. 
 
 It is convenient clinically to divide these tumours into the 
 subperitoneal, the interstitial, and the submucous. In the 
 beginning all are interstitial. 
 
 I. In the Corpus Uteri. 
 
 Subperitoneal. — These are tumours which grow outwards 
 toward the peritoneum. They tend to become pedunculated. 
 The pedicle may vary greatly in length and thickness ; con- 
 sequently the tumours vary in their range of movement. If 
 a tumour grows upwards, having a short pedicle, it tends to 
 pull up the uterus, elongating it ; sometimes the uterus may 
 be almost or completely torn across by this gradual traction. 
 
 ill some cases the tumour may lie in the pelvis from the 
 beginning, or may gradually fall down as its pedicle elon- 
 
V 
 
 474 
 
 FIBROMYOMA UTERL 
 
 / 
 
 uterus, pressing 
 bladder. 
 
 on 
 
 gates ; it may become impacted, incarcerated, or adherent. 
 
 Sometimes a subperitoneal tumour may grow into the broad 
 
 ligament. 
 
 Adhesions may take place owing to peritonitis, and ascitic 
 
 fluid may be produced. Adhesions 
 are most frequent to great omentum 
 and intestine ; sometimes a loop of 
 gut may be very intimately fused with 
 the tumour wall. These adhesions 
 may lead to increased growth in the 
 tumour. Sometimes a thin pedicle 
 Fig. 167.— Small fibroid may be broken through, e.^^. in preg- 
 of anterior wall of nancy or labour, or as a result of tor- 
 sion. After such a separation it usually 
 gets nourishment through its adhesions. 
 
 In many of these tumours, there are few vessels in the 
 
 pedicle ; they tend to form very slowly, and often become 
 
 very hard and shrink or calcify. 
 
 Torsion of the pedicle may sometimes occur, leading to 
 
 oedema and congestion in the 
 
 tumour, and to peritonitis over 
 
 it. Thrombosis occurs in the 
 
 vessels of the pedicle, and it 
 
 may become broken across. 
 
 Suppuration or gangrene may 
 
 follow in some cases. 
 
 Interstitial. — These are the 
 
 tumours which, as they grow, 
 
 cause the uterine wall to ex- 
 pand equally around them. 
 
 Many may be found in the 
 
 wall. As they grow they push the peritoneum outwards; 
 
 and the mucosa inwards, so that sometimes it may be 
 
 difficult to distinguish them from subserous and submucous 
 
 forms. It is best to denominate as interstitial those in 
 
 which the capsule is of equal thickness all round. As they 
 
 Fig. i68. — Retroflfixed uterus with 
 interstitial fibroids.. 
 
 (\ 
 
IN THE CORPUS UTERI. 
 
 475 
 
 Fig. 169. — Coronal section of pelvis in 
 which a fibromyoma of the uterus 
 is growing into the right broad 
 ligament. 
 
 grow, they tend markedly to bring about a hypertrophy of 
 
 the uterus. Often at one point the wall may be thinned 
 
 either on the peritoneal 
 
 or the mucosal side. 
 Where there is one 
 
 large intramural fibroid, 
 
 the whole uterus is some- 
 what rounded. When 
 
 there are several, it is 
 
 irregular. The uterus 
 
 may be displaced in 
 
 various directions; 
 
 sometimes it may be 
 
 flexed. It may grow 
 
 downwards into the 
 
 pouch of Douglas, or 
 
 into the cervix and vagina, or it may gradually fill up 
 
 the pelvis. 
 
 In some cases the tumour may grow outwards into the 
 
 broad ligament. 
 
 Submucous. — These are the tumours which tend to pro- 
 ject especially into the uterine cavity. Great 
 variations are found in their size and in the 
 size of the pedicle ; the latter may be short 
 or long, or nothing worthy the name may 
 exist. They are covered with uterine 
 mucosa, and a thin layer of musculature 
 which helps to form a capsule ; this may 
 be very thin at points. Sometimes no 
 
 Fig. i7<^Fi^broid muscular covering may exist. 
 
 polypus of the In the early stages, the mucosa covering it 
 
 uterus extending jg hypertrophied, as in the iv.st of the cavity ; 
 
 agina. ^^ ^^ tumour increases it usually atrophies. 
 
 Uterine action tends to force the tumour more and more 
 
 down. This is often most marked during the engorgement 
 
 due to menstruation. The tumour, being congested and 
 
V 
 
 476 
 
 FIBROMYOMA UTERI, 
 
 
 enlarged, stimulates the uterine musculature to increased 
 contractions. A pedunculated submucous tumour is usually 
 rounded or oval. Sometimes, owing to the constriction of 
 the cervix as it is driven down, it may be shaped like an 
 hour-glass. 
 
 Sometimes the capsule and mucosa covering the tumour 
 may be broken or gradually thinned, so that spontaneous 
 enucleation may follow. It may also ulcerate through. 
 Adhesions may take place to the wall of the uterus as a 
 result of inflammation or ulceration. 
 
 Sometimes in the course of enucleation the pedicle may 
 become constricted by the contraction of the musculature 
 of the capsule around it, and suppuration or gangrene may 
 follow. This may also follow infection from ulceration or 
 from operative procedures. 
 
 
 I 
 
 II. In the Cervix. 
 
 Fibroids rarely occur in this situation. They may develop 
 in any position in the cervix. If in the lower part, they 
 may give the cervix a rounded or elongated shape, or may 
 become polypoidal. They may project into the cervical 
 canal or into the vagina. 
 
 When they develop in the upper part they may grow 
 under the pouch of Douglas, between the bladder and 
 uterus, or into the broad ligaments. Various structures 
 may in this way be displaced, and the pelvis may become 
 greatly filled up. 
 
 Etiology. — The exact origin of fibromyoma is not known. 
 Klebs and others believe they take their origin from the 
 walls of blood vessels. Kleinwachter thinks they spring 
 from degenerated capillaries. According to Cohnheim's 
 theory, they arise from embryonic residues not used in the 
 normal development and growth of the uterus. They are 
 related to the period of sexual activity, and are practically 
 not known to develop before puberty or after the menopause. 
 
 ( \ 
 
IN THE CERVIX. 
 
 477 
 
 They occur with special frequency among the African 
 races. 
 
 Symptoms. — Haemorrhage from the uterus is a very 
 marked symptom in many cases. It occurs as menorrhagia 
 or metrorrhagia, and usually develops gradually, not sud- 
 denly, as in carcinoma. This symptom is found with 
 tumours in the region of the mucosa, which is generally 
 altered by interstitial endometritis in such cases. The worst 
 bleeding occurs when submucous tumours become poly- 
 poidal. Sometimes haemorrhage is due to ulceration of the 
 mucosa over the tumour. Rarely rupture of veins in the 
 capsule causes it ; it may be sudden and fatal. Death from 
 haemorrhage is, however, very rare. 
 
 With subperitoneal fibroids there are not necessarily 
 any hsemorrhagic symptoms, but they may sometimes be 
 found. 
 
 Leucorrhcea is present in many cases, but it is not dis- 
 tinctive. Probably it is most marked where the endometritis 
 is of the glandular type. It is often irregular. Just before 
 and after menstruation, there is usually a profuse mucous 
 discharge. The discharge is foul smelling when ulceration 
 or gangrene occurs. 
 
 Pains are common. They may be only of a heavy 
 dragging nature, with reflex abdominal and lumbar distress. 
 In many cases these are felt first at menstrual periods. 
 
 With subperitoneal fibroids, there may be pain due to 
 peritonitis, to torsion, to their large size, to their falling mto 
 the pelvis and there causing pressure or being impacted. 
 
 Dysmenorrhoea may be very intense. The pains may be 
 like those of labour in the case of submucous polypi, owing 
 to the efforts of the uterus to expel the tumour congested 
 by the menstrual period. They may also be very intense 
 if an interstitial or a prolapsed peritoneal tumour fills the 
 pelvis ; the suffering is due to the swelling which the tumour 
 undergoes. In many cases there are pains in the legs. 
 
 Pressure symptoms are common. — The bladder may be 
 
 HmiHi 
 

 ■■i>tT\. \*^yiin' n 
 
 V 
 
 478 
 
 FIBEOMYOMA UTERI. 
 
 interfered with, causing dysuria, difficulty in micturition, 
 or retention. In some instances these may only develop at 
 menstrual periods. 
 
 A small fibroid of the anterior uterine wall may cause 
 symptoms of cystitis. Sometimes the neck of the bladder 
 may be pressed on, causing chronic over-distension of the 
 bladder. In a few cases actual cystitis may develop in con- 
 nection with an imperfect emptying of the bladder. 
 
 •Compression of the ureters may lead to hydronephrosis, 
 pyelonephritis, or pyelitis. 
 
 Diseased conditions of the kidney seem to account for 
 a considerable proportion of deaths after operation in 
 myoma uteri. 
 
 Pressure on the rectum may lead to constipation, which 
 may be very troublesome j to obstruction ; occasionally to 
 diarrhoea. Pressure on veins may cause haemorrhoids or 
 varicose veins in the legs. Pressure on nerves, besides 
 causing pains, may bring about weakness and numbness 
 in the lower limbs. 
 
 The heart may be secondarily affected when the tumour 
 is of any size, — due to increased blood pressure, — and weak- 
 ness may result, though there may be no very definitive 
 symptoms. 
 
 Sterility is common as a result of these tumours. If 
 pregnancy takes place, abortion or premature labour may 
 result. If the case go on to full time, there may be diffi- 
 culty in delivery, and danger in the third stage. 
 
 Progress of the disease. — Interstitial fibroids are be- 
 lieved sometimes to disappear by involution and absorption. 
 A few cases have been recorded, the majority of which 
 have been met with in the puerperium ; the rest at the 
 menopause. 
 
 The usual change at the menopause is a mere diminu- 
 tion in size, the tumour becoming harder. 
 
 A subperitoneal fibroid may become separated from the 
 uterus, and may grow in connection with other structures. 
 
 W 
 
 JL 
 
IN THE CERVIX. 
 
 479 
 
 A submucous tumour may be expelled as a polypus, or may 
 be spontaneously enucleated from its capsule, or may 
 be discharged as a result of suppuration or gangrene. 
 Sometimes a suppurating tumoui may burrow into sur- 
 rounding parts, open into the peritoneum, vagina, or viscera. 
 
 Death from fibromyoma may be due to sudden great 
 loss of blood ; to peritonitis, with or without torsion of the 
 pedicle ; to uraemia ; to suppuration or gangrene \ to long- 
 continued loss of blood and exhaustion, probably aided in 
 some cases where there is much constipation by a con- 
 dition of copraemia. 
 
 Physical signs — When the tumour is small. — Small sub- 
 mucous tumours which are pedunculated may be felt 
 when the cervix is dilated so as to admit a finger. When 
 they project through the cervix, they are red in colour while 
 covered with uterine mucosa. When the mucosa has dis- 
 appeared, they are usually pale in colour. When covered 
 with mucosa, they are sensitive to pain ; when uncovered, 
 they are not sensitive. Sometimes such a tumour, bulging 
 through the cervix, may be in a condition of ulceration or 
 gangrene, rendering the diagnosis difficult from malignant 
 disease. 
 
 The whole uterus is increased in size with these 
 tumours. 
 
 Small submucous tumours non - pedunculated may be 
 difficult to diagnose. The uterus is increased in size and 
 rounded. The swelling of the tumour may be felt bi- 
 manually. On dilating the cervix, the exploring finger may 
 feel the elevation, covered with soft mucosa, interfering with 
 the lumen of the uterus. 
 
 Small interstitial tumours may be easily missed. Some 
 enlargement of the uterus may be felt, and the nodule or 
 nodules may or may not be felt according to their size. 
 The higher in the uterus they are, the more apt are they to 
 be missed. When low in the uterus, they may bulge down 
 the cervix, and be mistaken for inversion. 
 
 v\ 
 
V 
 
 480 
 
 FIBROMYOMA UTERI. 
 
 These various submucous and interstitial fibroids must 
 be diagnosed from the following : — 
 
 Inversion of the uterus. 
 
 Chronic metritis. 
 
 Early pregnancy. 
 
 Anteflexion and retroflexion. 
 
 Endometritis. , , 
 
 Malignant disease of the uterus. 
 
 Small subperitoneal tumours are felt on careful bimanual 
 examination attached to the uterus. The uterus is not 
 necessarily large. 
 
 They must be diagnosed from — 
 
 Swellings of the ovary and tube. 
 
 Swellings in the broad ligament. 
 
 Floating kidney. I 
 
 A cervical fibroid may be felt as a polypus projecting 
 from the cervix, smooth and elastic. Close to it may be 
 felt the OS. The opposite lip may be somewhat thinned. 
 Sometimes they may grow as polypi into the canal of the 
 cervix. When they develop in the upper portion of the 
 cervix, they may be felt developing extraperitoneally in one 
 or more directions. 
 
 The large polypoidal forms must be distinguished from 
 polypi of the interior of the uterus, and inversion of the uterus. 
 Those growing from the upper part of the cervix, and extend- 
 ing into surrounding tissues, may be mistaken for sarcoma. 
 
 When the tumour is large. — A large mass is found, 
 regularly or irregularly rounded or very irregular in outline. 
 It can be distinctly defined usually. If the tumour be sub- 
 peritoneal, its connection with the uterus may be made out 
 with the uterus, though this may be impossible ; it may be 
 felt elongated and elevated. The sound may be passed to 
 an abnormal length. These tumours vary in their range of 
 movement according to their size, the length of their pedicle, 
 and the adhesions which the tumour possesses. The uterus 
 is displaced in various ways. 
 
 I \ 
 
IN THE CERVIX. 
 
 481 
 
 When the tumour is interstitial, the uterus becomes 
 part of the mass. VVlien it grows into the broad ligament, 
 it has the relations of a broad ligament tumour {yide 
 p. 382). 
 
 A soft myoma may on palpntion give the feeling of a 
 cystic tumour. 
 
 The percussion note over the tumour is dull, unless it 
 be covered with intestines. There is usually resonance in 
 the flanks unless the colon contains faeces, unless there 
 be ascitic fluid in the abdomen, or unless there be a 
 mass of the tumour growing into the region of the loins 
 (or some other mass). On changing the position of the 
 patient, the percussion signs do not alter, unless there is a 
 movable subperitoneal tumour or ascites along with the 
 tumour. 
 
 A uterine souffle is generally heard over the broad liga- 
 ments, and may be distinguished for a short distance on 
 the tumour. In very vascular fibroids, it may be heard 
 over the great mass of the tumour in rare cases ; occa- 
 sionally a thrill can be felt. 
 
 The uterine cavity is enlarged. In some cases, owing to 
 the displacement of the organ, it is impossible to pass a 
 metal sound into it ; a gum-elastic catheter or bougie may 
 often be introduced where the ordinary sound fails. 
 
 Differential diagnosis of large tumours — 
 
 1. From advanced utero-gestation. 
 
 2. From ovarian and broad ligament, cystic and solid 
 tumours. 
 
 3. Ectopic gestation. 
 
 4. Hasmatoma and hoematocele. 
 
 5. Inflammatory diffusions and deposits. 
 
 6. Cystic uterine tumours. 
 
 Treatment — Medical. — If the tumour be growing at 
 a rapid rate, it is best to give the patient a low diet, avoiding 
 stimulants. When much discomfort or pain is complained 
 of, she should give up a portion of her work, and should 
 
 31 
 
 \\ 
 
V 
 
 4&2 
 
 I'IBROMYOMA UTERI. 
 
 / 
 
 rest for two or three hours per diem, and at the menstrual 
 period should rest almost entirely. 
 
 Very often when tumours of not too great size cause 
 dragging and bearing-down pains, a Hodge or ring pessary 
 may give relief by supporting the uterus ; a binder may give 
 support when the tumour is large. 
 
 When a tumour tends to grow in the pelvis, it should be 
 pushed above the brim from time to time, so that it may not 
 become impacted. 
 
 Patients often improve considerably by courses of treat- 
 ment at baths, e.g. the muriated baths of Kreuznach, those 
 like the Salies-de-Bdarn waters, which contain bromides or 
 iodides. 
 
 Ergot in its various forms is a valuable drug. It may be 
 given by the mouth or hypodermically. It tends to check 
 bleeding, and often prevents the increase of the tumour by 
 the contraction of blood vessels which it brings about. It 
 is said that it aids in the expulsion of a pedunculated sub- 
 mucous tumour. 
 
 Excessive dosage may produce cramps in the limbs, 
 fever, vomiting; it is also stated that it may have some 
 influence in causing suppuration or gangrene in the tumour. 
 Hydrastis canadensis is also used as a haemostatic by many 
 physicians. It may be given in twenty- to thirty-drop doses 
 three or four times a day. 
 
 Bromide of potassium was used by Sir J. Y. Simpson, 
 who thought that it could check the growth and diminish 
 the size of fibroids. Probably it has only a sedative action 
 against pain. Arsenic and iron may often be necessary as 
 tonics. 
 
 Electrical. — Galvanic electricity has been largely em- 
 ployed in the treatment of fibroids. The extravagant 
 claims made by its advocates on its first introduction 
 must be abandoned. It does not cause disappearance of 
 tumours, but only relieves symptoms for a greater or less 
 extent of time. 
 
OPERA Tl VE PROCED URES. 
 
 483 
 
 Cases in which disappearance after its use has been noted 
 have probably not been fibroids at all, but inflammatory or 
 blood deposits. 
 
 The details as to treatment are discussed elsewhere. 
 
 Surgical. — Curettage. — Often the hremorrhagic loss from 
 the uterus may be checked for a time by curetting the 
 uterus, and employing a styptic like perchloride of iron. 
 It should only be tried when the whole cavity can be 
 explored. 
 
 Dilatation of the cervix. — This procedure may cause 
 relief of pain, and be followed by less hremorrhage in some 
 cases. It may be tried on cases near the menopause, where 
 a serious operation is not desired. 
 
 Ligation of the uterine arteries. — This operation is 
 recommended by Martin of Chicago, Goelet, and others, as 
 a simple means of improving symptoms, of checking rapid 
 growth, and of leading in some cases to a diminution in 
 the size of the tumour. The operation is performed per 
 vagiram. It is best to apply a couple of ligatures on each 
 side. Care must be taken not to injure the ureters. Some- 
 times it is only possible to apply the ligature on one side. 
 
 Major Operative Procedures. 
 
 Fibromyoma of the uterus. — Subperitoneal tumours. 
 — Subperitoneal pedunculated fibroids require treatment 
 when they cause pressure symptoms, or are apt to become 
 incarcerated in the pelvis, or when they grow into the broad 
 ligament. Sometimes, in the course of an operation for 
 some other cause, e.g. salpingo-ovaritis, they may be removed. 
 These tumours should be removed by abdominal section. 
 
 If the growth possess a small pedicle, it is ligatured by 
 the Staffordshire knot or by interlacing sutures, the tumour 
 being cut away outside the ligature. If the pedicle be a 
 thick one, three or more interlacing sutures should be 
 employed. Before passing the needle through a thick 
 
484 
 
 FIBRO MYOMA UTEKL 
 
 / 
 
 pedicle, it is best to place a temporary elastic ligature 
 around the uterus as low as possible. This is taken off 
 after the tumour is cut away. If there be any oozing 
 through the stitches, a few deep catgut sutures are passed 
 and tied. 
 
 When the intestine is attached by adhesions to the 
 tumour, they should be removed in the ordinary manner, if 
 slight. If they are firm and extensive, the superficial layer 
 of the fibroid should be dissected off and left on the bowel, 
 the raw surface being closed by continuous catgut sutures. 
 
 Interstitial tumours. — {a) Single and of moderate 
 size. — Such growths may give rise to symptoms, e.g. pain, 
 for which operative treatment may be deemed necessary. 
 
 Sometimes symptoms may be checked by ligature of the 
 uterine artery on each side. This is done with a fuU-curvtd 
 needle and a Martin's needle-holder. 
 
 A circular incision is made through the mucosa covering 
 the vaginal portion of the cervix, and the flap is stripped 
 upwards, as in the operation iyc circular amputation of the 
 cervix. When the level of the uterine arteries is reached, 
 the vessels are secured with catgut sutures. The stripped- 
 up flaps are then pulled down and stitched in their former 
 position. 
 
 If the patient be not near the menopause, the following 
 operation is recommended by many authorities. 
 
 Enucleation by abdominal section. — Before the operation, 
 the vagina and uterine cavity should be made aseptic. 
 After the abdomen is opened, the uterus is drawn up and 
 surrounded with hot gauze pads. An elastic ligature is 
 placed temporarily around the cervix and broad ligaments. 
 
 The capsule of the tumour is incised, and the growth 
 enucleated, care being taken not to open into the uterine 
 cavity. v 
 
 The cavity is then closed either by continuous catgut 
 suture or by a series of interrupted sutures passing under 
 the whole extent of the wound. 
 
OPERATIVE PROCEDURES. 
 
 485 
 
 If the uterine cavity be opened into, the mucous mem- 
 brane should be stitched together with catgut, and the 
 rest of the wound closed as described. 
 
 If a large opening be made, an iodoform gau/e strip 
 should be passed down through the cervix to act as a drain, 
 while as much of the wound as pcssible should be closed. 
 
 Sometimes a very large opening may be made. If the 
 closure of the wall be difficult, the question of extirpating 
 or amputating the uterus may arise. 
 
 Removal of appendages. — If, however, the patient be near 
 the menopause, the best operation to perform is salpingo- 
 oophorectomy, or removal of the appendages. This is 
 performed by abdominal section. Anteri' - colpotomy is 
 recommended by some, for this purpose, wljcii the tumour 
 is of small size. 
 
 The method of removing the appendages is the same as 
 in the case of their removal for inflammatory disease. Care 
 must be taken to remove the whole tube, and to secure as 
 much of the broad ligament in the pedicle as possible. If 
 it is not possible to take in a large portion of the ligament, 
 it is wei' to secure the ovarian artery by a special ligature 
 around the infundibulo-pelvic ligament. 
 
 {b) Single, large, or multiple small fibroids. — Various 
 operations are performed when these conditions cause 
 distressing symptoms — 
 
 1. Removal of the appendages. — This method has just 
 been described. 
 
 2. Amputation of the uterus^ or supravaginal hysterectomy. 
 {a) By the intraperitoneal method. — Beforehand, the 
 
 vagina and uterine cavity are made aseptic. 
 
 The abdomen is opened in the middle line. In cutting 
 towards the symphysis, care must be taken not to wound 
 the bladder, which may be displaced upwards. If there are 
 any cystic portions, whose puncture will allow of a diminu- 
 tion in size of the tumour, they should be emptied, if 
 accessible. The abdominal opening must be large enough 
 
 ■■; S 
 
TT 
 
 486 
 
 FIB ROM YO MA UTERI. 
 
 J 
 
 to allow the tumour to be lifted out. If necessary, the 
 opening may be enlarged by an incision at right angles to 
 the first one. The relations of the bladder must now be 
 studied, a male sound being passed into it. It is best in 
 such cases that the patient should not empty the bladder 
 before operation, in order that its position may be better 
 defined on opening the abdomen. 
 
 If it is very high, it may require to be separated somewhat 
 from the tumour. 
 
 Adhesions to the tumour are separated. 
 The broad ligaments must now be ligatured, first on one 
 
 side and then on the 
 other, in order to 
 secure the vessels. 
 
 If the tumour mass 
 be not too great, this 
 may be accomplished 
 while the parts are in 
 the abdomen. If the 
 mass be large, it is 
 best lifted out of the 
 abdomen. The 
 bowels should at this 
 stage be prevented 
 from being exposed 
 to the air. If necessary, aseptic warm pads may be placed 
 over them. 
 
 The ligatures are applied from above downwards, first on 
 one side and then on the other. No 4 catgut may be used, 
 or strong pedicle silk. Each is passed double by means 
 of a pedicle needle. The needle is first passed below the 
 ovarian artery in the outer part of the broad ligament, care 
 being taken not to penetrate a vein. 
 
 The needle is removed, and the ligature is divided. The 
 halves are then pulled apart for about half an inch or more, 
 a transverse split being made in the ligament. 
 
 FiC 171. — Supravaginal hysterectomy. 
 Method of ligaturing broad ligaments. 
 
OPERATIVE PROCEDURES. 
 
 487 
 
 Fig. 172. — Supravaginal hysterectomy. 
 Application of elastic ligature. Line of 
 incision above ligature is shown. 
 
 The outer ligature is next tied outside the ovary and tube, 
 the inner one being tied internal to the ovary. The liga- 
 ment is then divided 
 between the liga- 
 tures almost as far 
 down as the slit. The 
 needle is again passed 
 through the ligament 
 at a lower level, but 
 closer to the uterus, in 
 order to avoid the ure- 
 ter, and the same pro- 
 cedure carried out. 
 The needle may be 
 passed again if neces- 
 sary, in order to secure 
 the uterine arteries thoroughly. The ligament is thus 
 divided as low down as the cervix. 
 
 An elastic ligature is then fastened around the cervix 
 
 tightly, the ends being held 
 in a piece of grooved vul- 
 canite or a pair of strong 
 forceps. 
 
 A circular incision is 
 then made at least 3 cm. 
 from the ligature through 
 the peritoneum cover- 
 ing the uterus - tumour 
 mass. 
 It is stripped downwards for a little, and then the rest of 
 the mass is cut circularly, the knife blade being directed 
 downwards somewhat. The tumour is then removed. The 
 stump now remains to be secured, the raw surface being 
 funnel-shaped. The cervical canal must be thoroughly 
 cauterised with the Paquelin cautery or with strong carbolic 
 acid. 
 
 Fig. 173. — Supravaginal hysterectomy. 
 The diagram shows the stump of the 
 uterus left at close of operation. 
 
V 
 
 488 
 
 FIBROMYOMA UTERI. 
 
 \ 
 
 A series of interrupted catgut sutures are first passed 
 through the whole thickness of the wound. Before they are 
 tied, the raw surface of the stump is closed by means of a 
 carefully applied continuous catgut suture passed in stages 
 from the bottom to the top of the wound. The peritoneal 
 edges should be carefully brought together. The separate 
 stitches should then be tied somewhat obliquely to the 
 vertical axis of the stump. 
 
 The wound should be closed from side to side, i.e. the 
 peritoneal edge should lie antero-posteriorly. 
 
 The elastic ligature is now removed. If there is any 
 bleeding from the stump, either of the following plans may 
 be adopted. The uterine arteries may be further secured 
 on each side by means of a needle and catgut ligature ; the 
 collateral circulation will be sufficient to supply the stump. 
 Or the stump may be pierced and ligatured in two halves 
 by interlacing sutures. 
 
 Several variations are found in the method of carrying 
 out this operation. Thus Gardner and others first ligature 
 the broad ligaments from the infundibulo-pelvic borders to 
 the edge of the upper part of the uterus. This secures the 
 ovarian arteries, and enables the appendages to be cut 
 away. The round ligaments are ligatured and divided, and 
 an incision made around the uterus, dividing the peri- 
 toneum on a level with the line of division in the broad 
 ligaments. The peritoneum below this incision is then 
 stripped down. When the uterine arteries are reached, 
 they are ligatured. The tumour is then cut away at the 
 desired level, and the stump is closed in by interrupted and 
 continuous catgut sutures. No elastic ligature is used in 
 this modification. 
 
 After careful cleansing of the peritoneum, the abdomen 
 is closed. . 
 
 Note. — This operation may be a prolonged one, and there may be 
 much shock. There is danger of after-ha^raorrhage, sloughing of the 
 stump, and sepsis. 
 
 t \ 
 
OPERA TI VE PRO CED URES. 
 
 4S9 
 
 (b) By the extraperitoneal method. — The broad ligaments 
 are secured and divided, as already described. The elastic 
 ligature is then passed twice 
 around the uterus, and secured. 
 Forceps are attached to the stump 
 outside the ligature, and the 
 tumour mass is cut away about 
 two finger-breadths above the 
 ligature. If any small fibroids 
 are seen in the raw end of the 
 stump, they are removed. Any 
 vessels noticed may be tied. The 
 peritoneal cavity is then cleansed. 
 
 The elastic ligature should be 
 placed so as to act as a per- 
 manent ligature. If it has been 
 placed too far down on the uterus, 
 another may be applied outside 
 it, the first one being removed. 
 
 If there be no special catch for 
 holding the ends of the elastic 
 ligature, they may be secured 
 with strong silk ligature. 
 
 Some operators tie the pedicle 
 with silk outside the elastic band. 
 Instead of the elastic ligature, 
 Koeberle's serre-noeud may be 
 used. 
 
 The peritoneum below the 
 elastic ligature should next be 
 carefully stitched to the pv^ri- 
 toneal edges of the lower angle 
 of the wound. 
 
 The remainder of the peritoneal edges of the wound 
 should now be closed with continuous catgut suture. Then 
 the muscular and facial layers are brought together in the 
 
 Fig. I7^.- 
 
 -Koeberl^'s serre- 
 noeud. 
 
r 
 
 / 
 
 / 
 
 490 
 
 FIBKOMYOMA UTERI. 
 
 X 
 
 ^c 
 
 same way ; not, however, within an inch of the stump. 
 The skin edges are then brought together to within an inch 
 from the stump. 
 
 The pedicle is next pierced by two strong pins, placed 
 nearly at right angles j the sharp ends must be fitted 
 with caps. Iodoform gauze is placed beneath them. In 
 this way the pedicle is prevented from sinking into the 
 pelvis. The stump is then neatly trimmed, the mucosal 
 
 and the raw surface being 
 cauterised with a Paquelin 
 cautery. 
 
 In the cavity surrounding the 
 stump, naphthalene powder or 
 naphthalene mixed with salicylic 
 acid powder or iodoform is 
 sprinkled, and it is filled with 
 iodoform gauze. The pedicle is 
 covered with the same powder, 
 the usual dressings are then 
 placed on the abdomen, and the 
 patient is put to bed. 
 
 After-treatment. — In eight or 
 nine days the dressing is changed, 
 Fig. 175.— Fixation of the ped- though sometimes it is necessary 
 icle in the extraperitoneal ^-q ^0 SO beforehand. It is best 
 
 method.— After Pozzi. ^u i. ^.u j u 1 1 u j- 
 
 that the wound should be dis- 
 turbed as little as possible. Between the second and third 
 week the elastic ligature, the stump, and the pins usually 
 drop off. The resulting cavity lined wiLh granulation 
 tissue is dressed with iodoform gauze-packing from day 
 to day. 
 
 Otherwise, the after-treatment is the same as after an 
 ovariotomy. The patient should not rise until the cavity 
 has begun to fill up. 
 
 Note. — This method, it is evident, can only be adopted when a 
 sufficiently long pedicle can bo obtained. It is associated with risk of 
 
 f\ 
 
OPERATIVE PROCEDURES. 
 
 491 
 
 sepsis from sloughing of the stump. Sometimes the pedicle retracts, 
 and the peritoneum is opened. The resulting scar is a weak one. An 
 abdomino-cervical fistula may remain. If the appendages be left 
 behind, hiemorrhage may occur from the wound at menstrual periods. 
 
 In favour of this operation is the rapidity with which it can be per- 
 formed as compared with the intraperitoneal method. 
 
 Wolfler modification. — This operation is carried out as in 
 the case of an intraperitoneal amputation. The stump is 
 then brought to the lower part of the abdominal incision, to 
 the edges of which it is stitched by means of sutures passed 
 through the thickness of the abdominal walls. The ab- 
 dominal wound is then closed, save immediately over the 
 stump. The opening left is packed with gauze. 
 
 Note. — This operation possesses the advantage of the other extra- 
 peritoneal method, without the risks attendant upon the separation of 
 the pedicle. Adhesion soon takes place between the stump and the 
 abdominal wall, the opening above the stump gradually closing by 
 granulation tissue. 
 
 {c) Panhysterectomy. — It is believed by many that com- 
 plete removal of the uterus, along with the tumour, is a less 
 dangerous operation than amputation. As yet it is im- 
 possible to decide regarding this point. It has been very 
 successfully employed by some operators, e.g. Martin of 
 Birmingham, and will undoubtedly occupy an important 
 place in the future treatment of fibroids. 
 
 The patient is prepared as has already been described. 
 After the incision is made in the abdomen, and the tumour 
 lifted out, the broad ligaments are secured and divided as 
 low as the cervix, in the manner described on p. 486. The 
 reflection of the peritoneum to the cervix is then divided 
 transversely, and the bladder separated as far as the vaginal 
 wall. 
 
 An assistant then passes a sound up the vagina, and 
 presses in the anterior fornix, in order to furnish a guide to 
 the operator, who cuts upon it, and then divides the whole 
 anterior fornix transversely. 
 
!■■ 
 
 V 
 
 492 
 
 FIBROMYOMA UTERI. 
 
 The lowermost portion of the broad ligament is then 
 ligatured, the needle being passed just above the vaginal 
 surface. Care must be taken not to embrace the ureter. 
 It may sometimes be recognised by its white colour. The 
 broad ligaments are then cut through, and the posterior 
 fornix is divided close to the uterus. 
 
 The tumour mass is then removed. The peritoneum 
 and vaginal mucosa should next be approximated all round 
 the opening in the vagina, by means of continuous catgut 
 suture. The pelvis is then cleaned, and the ends of the 
 lower ligatures, if of silk, brought into the vagina. When 
 catgut is used, the ends are cut short. A round mass of 
 
 iodoform gauze is 
 fitted into the open- 
 ing, its ends passing 
 into the vagina to act 
 as a drain. The ab- 
 domen is then closed, 
 and the patient placed 
 in bed. 
 
 After - treatment. — 
 This is much the 
 same as after intra- 
 peritoneal amputation. The urine should be drawn off 
 every six hours for five days. The iodoform gauze should 
 be removed on the second or third day, and a fresh vaginal 
 plug introduced. After ten or twelve days, vaginal anti- 
 septic douches may be carefully given with a large double 
 catheter. < 
 
 Intraligamentous fibroids. — These are fibroids which 
 generally grow from the cervix or lower part of the 
 body of the uterus, and extend into the extraperitoneal 
 connective tissue. They may grow into the mesorectum, 
 or displace the bladder in some cases. Most extend 
 laterally into the broad ligament. In these cases, re- 
 moval is often very difficult owing to the immobility of 
 
 Fig. 176. — Fixation of the pedicle by 
 Wolfler's method.— After Poz^i. 
 
 \\ 
 
OPERATIVE PROCEDURES. 
 
 A93 
 
 I 
 
 ■■'i 
 
 the masi?, the absence of a pedicle, and the relationship to 
 viscera. 
 
 Small tumours may be removed easily. Large ones often 
 cannot be removed. When removal is impossible, the ap- 
 pendages should be taken away, and the broad ligament on 
 the side opposite the tumour should be ligatured and divided. 
 
 If extirpation of the mass be attempted, the ovarian 
 artery in the outer part of the broad ligament should be 
 ligatured. If possible, the uterine artery on the same side 
 should be secured. 
 
 A long incision should be made through the ligament- 
 ous covering of the tumour, which should then be drawn 
 upwards with a strong volsella, while with the fingers and 
 a spatula it should be shelled out. Bleeding vessels are 
 caught with forceps. The ureter must be avoided. 
 
 If there is a small pedicle attached to the uterus, it 
 may be ligatured with interlacing silk sutures. If it be 
 impossible to carry this out, the whole uterus should be 
 extirpated. If, also, after the removal of the tumour, the 
 arrest of bleeding is difficult, the operator should also pro- 
 ceed to the removal of the whole uterus. 
 
 After removal of the tumour, if extirpation of the uterus 
 be not necessary, the next step is to treat the bed of the 
 tumour. The raw surfaces should be brought together by 
 continuous catgut suture. 
 
 The pelvis is then carefully sponged. If there be any 
 oozing, drainage is carried out by means of a glass tube 
 through the abdominal wound. 
 
 Another method is to make an opening from the cavity 
 occupied by the tumour into the vagina, to place gauze 
 in the sac, the ends being passed into the vagina. The 
 incision that was made into the peritoneal covering of the 
 tumour is then closed, and the abdominal wound stitched. 
 The gauze is removed in a few days per vaginam, and daily 
 antiseptic douches are given afterw^ards by i leans of a 
 double catheter. 
 
 v, 
 
 t5^^^;rrr-T(«?C3y;r«v<r"»^>*f^'?^*'-^^-' "^^ 
 
494 
 
 FIBROMYORIA UTERI. 
 
 Submucous fihroids of the body. — (a) Pedicu/ated. — 
 In the great majority of cases, removal by way of the vagina 
 is to be performed. The patient is placed in the lithotomy 
 position. The genital tract is made aseptic. When the 
 polypus does not project through the os externum, or only 
 slightly through, dilatation of the cervical canal should be 
 carried out in the first place. This may be done with a 
 sponge-tent the night before the operation, and with Hegar's 
 dilators at the operation. When, in this manner, sufficient 
 room cannot be obtained for the securing of the pedicle, 
 the following procedure should be adopted : — The cervix 
 should be steadied with a volsella, and the junction of the 
 anterior vaginal wall and cervix divided transversely, the 
 bladder being stripped upwards as far as the os internum. 
 The anterior lip of the cervix is then divided in its whole 
 length, bleeding points being held with forceps. In this 
 way room is obtained. 
 
 Various methods of treating the pedicle are adopted. 
 If small, the tumour may be held with forceps, and twisted 
 off. Or, if large, twisting may be combined with snipping 
 of the pedicle with scissors. The pedicle should not be 
 divided close to the uterine wall. 
 
 Some operators prefer to transfix the pedicle and secure 
 it by means of strong pedicle silk, the tumour being cut 
 away below it. 
 
 Others prefer to cut slowly through the pedicle with the 
 serre-nceud or the ecraseur. Sometimes the nail-curette is 
 of use. 
 
 When the tumour lies in the vaginal canal, the procedure 
 varies in different cases. If the tumour be small, it may be 
 pulled down easily along with the cervix, and the pedicle 
 may be divided, as described above, inside the cervix. If 
 the tumour be large, it is necessary to reduce it in size before 
 the pedicle can be reached. 
 
 This is best done by cutting circularly through the cap- 
 sule, shelling the tumour out as far up as possible, and then 
 
 t\ 
 
OPERATIVE PROCEDURES. 
 
 495 
 
 cutting away portion after portion of the tumour, bleeding 
 being checked by means of forceps. 
 When the pedicle is reached it may be 
 ligatured, and divided with the ecraseur 
 or with scissors. To pull down the 
 tumour, large strong forceps are re- 
 quired. 
 
 Sometimes, to gain access to the vagina, 
 it may be necessary temporarily to divide 
 the perineum on each side. 
 
 If the cervix should have been opened, 
 its edges should be closed, and tt i in- 
 cision into the anterior fornix stitched. 
 
 After the removal of every tumour, the 
 uterine cavity should be thoroughly 
 cleansed, and it should be packed with 
 iodoform gauze, along with the vagina. 
 This can be removed on the third day, 
 and antiseptic douches given daily after- 
 wards. After a week or ten days, it is 
 well to curette the whole uterus, so as 
 to remove the general mucosa, which is 
 more or less diseased, in order to stimu- 
 late the uterus to involution. Some 
 operators, however, prefer to perform 
 curettage at the time of removal of the 
 tumour. 
 
 {b) Non-pediciilated. — When the fibroid 
 is not pediculated, its removal is much 
 more difficult. If very large, the treat- 
 ment should be abdominal removal of 
 the appendages, or panhysterectomy, i.e. 
 
 if the symptoms demand operative inter 
 
 c Fig. 177.— a. R. Simp- 
 
 ference. ^ , ., 
 
 son s nail-curette. 
 
 Ligature of the uterine arteries may 
 alone be tried in some cases. Symptoms may be checked. 
 
immamm 
 
 V 
 
 496 
 
 FIBROMYOMA UTERI. 
 
 and the growth of the tumour retarded for a time by thrs 
 procedure. 
 
 Curetting may cause improvement in some haemorrhagic 
 cases. 
 
 Small tumours. — Where the tumour is small or of 
 moderate size, its removal may be undertaken by way of 
 the vaginti. The patient is placed in the lithotomy position, 
 the genital tract being made aseptic. The vagina should 
 have been stretched for several days by means of packing. 
 The cervix should be dilated. In order to gain more 
 room, it should be divided, as described on p. 494, and 
 again closed when the operation is ended. 
 
 If bleeding be feared, the uterine arteries of both 
 sides may be ligatured by means of a full-curved needle. 
 If the tumour be smaller than a closed fist, it may be 
 enucleated in toto. The most prominent portion is held 
 with a volsella. An incision as long as possible is made 
 through the capsule along the line of junction of the 
 prominent part of the tumour with the uterine wall. The 
 tumour is then shelled out of the capsule with the fingers 
 and a spatula, the mass being gradually drawn out with 
 forceps. 
 
 It may be necessary to cut some of the adhesions with 
 scissors. The tumour may be gradually twisted as it is 
 withdrawn. If it is rather large to pull down en masse, it 
 may be divided. 
 
 The bed of the tumour has now to be attended to. All 
 loose shreds of tissue are removed, a hot uterine douche 
 is given, and the raw cavity plugged with iodoform gauze, 
 which is prolonged into the vagina. 
 
 If the cervix has been divided, it is now closed, and the 
 patient put to bed. Ergot is administered daily. On the 
 fourth day the plug is removed, and antiseptic douches are 
 given daily. If there should be any fresh bleeding, plugging 
 can again be carried out. 
 
 Note. — The dangers of this operation are perforation of the uterus, 
 
 fV 
 
OPERATIVE PROCEDURES. 
 
 497 
 
 inversion of the uterus, httmorrhage, incomplete removal of the 
 tumour, septicaemia. 
 
 Larf^e tumours. — Removal of the mass bit by bit {mor- 
 cellcment) is employed by some operators. 
 
 1 he patient is prepared as for the other operations. The 
 cervix is first dilated somewhat. 
 
 'I'he junction of the vaginal mucosa to the cervix should 
 
 Fig. 178 — Morcellement. This diagram shows Richelot's 
 method. — DuN.v. 
 
 A. Volsella first applied to uterus. 
 
 B to I. Successive positions of volsella. 
 
 I to 6. Successive portions removed from anterior wall of uterus. 
 
 be circularly incised, and carefully stripped up as far 
 as possible. The cervix is then incised on each side, so 
 as to form an anterior and a posterior flap. Or it may 
 be divided, so as to form two lateral flaps. The incision 
 should reach up to the tumour. These flaps should 
 be held in strong forceps, separated and pulled down- 
 wards. 
 
 The prominent part of the tumour is then grasped with 
 strong toothed forceps. With retractors the cervix and 
 32 
 
V 
 
 498 
 
 FIBROMYOMA UTERI. 
 
 vagina arc opened as much as possible. An incision is 
 then made in the tumour at right angles to its longest axis. 
 One edge is grasped by forceps, and the jMece of tumour 
 cut away with scissors or knife below them. Before the 
 portion is removed, a grasp is taken above it with another 
 pair of forceps. 
 
 Usually the operation is not attended with much hnemor- 
 rhage. What there is comes chiefly from the divided cervix. 
 Forceps should be used to check this. If possible, pre- 
 liminary ligature of the uterine arteries may be employed 
 in order to diminish bleeding. 
 
 The removal of the tumour, piece by piece, is continued 
 until it is entirely taken away. Sometimes when the lower 
 part of the mass is removed, the upper portion may come 
 away by twisting it. In some cases more than one tumour 
 may be removed. ^ 
 
 If a small opening be made through the uterine wall into 
 the peritoneum, no particular measures need be adopted. 
 If a large one be made, total extirpation of the uterus 
 should be performed. If very extensive destruction of the 
 uterus be caused by the monel/emenf, total extirpation 
 should also be performed. 
 
 After the removal of the tumour, all bleeding points in 
 the raw bed should be seized with long forceps. The cavity 
 should be cleaned with an antiseptic douche, and between 
 the forceps an iodoform gauze plug should be placed in the 
 uterus. 
 
 After-treatment. — The patient is kept at rest and the 
 vagina is douched daily. In thirty-six or forty-eight hours 
 the forceps and gauze are removed, the uterus being washed 
 out. Jbrgot is given regularly. 
 
 Note. — This operation should only be attempted when there is a 
 definite submucous tumour. The risks of cutting into the peritoneum, 
 of haemorrhage, sepsis, and shock from prolongation of the operation, 
 are great. 
 
 It is impossible, as yet, to say whether this operation is 
 
 h 
 
OrERATIVE PROCEDURES, 
 
 499 
 
 safer or more dangerous than abdominal enucleation or 
 hysterectomy. 
 
 Fibroids of the vaginal portion of the cervix. — 
 (a) Pediculated. — These are removed in a manner similar 
 to that employed in the case of pediculated fibroids of the 
 body by way of the vagina. 
 
 (b) Interstitial. — These are they which cause a large 
 swelling in the cervix, and tend to grow towards neigh- 
 bouring parts, e.^. into the broad ligament. 
 
 If not too large, the covering should be divided, and 
 enucleation or nwrcellement should be carried out. 
 
 Sometimes one has to be satisfied with removing a part 
 of the tumour, the capsule being sewn over the cut end. 
 
 In some cases the part left may be gradually pushed 
 downwards by uterine action, so that it can be removed 
 by a second operation. 
 
 When a tumour is removed, the resultiug cavity may be 
 closed by continuous catgut suture or packed with gauze. 
 
 Care should be taken to avoid injuring the bladder or 
 ureter. 
 
 Death after abdominal hysterectomy. — Death after 
 this severe operation may be due to loss of blood, which may 
 occur at the operation or after it. The secondary haemor- 
 rhage may occur intraperitoneally or extraperitoneally. 
 
 It may be due to shock, which may be caused by loss 
 of blood, or to exposure and handling of intestines. No 
 doubt, many cases of so-called shock are really due to liga- 
 tion of the ureters, reflex interference with the function 
 of the kidneys, prolonged use of the anaesthetic, heart 
 degeneration. 
 
 Prolonged use of ergot, bromides, and iodides before 
 operation, may depress the patient so that it may affect 
 her seriously. 
 
 Embolism may sometimes cause death ; sometimes in- 
 testinal obstruction may lead to it. Sepsis is a very 
 important cause. 
 
V. 
 
 500 
 
 FIBROMYOMA UTERI. 
 
 / 
 
 Cystic Tumours of the Uterus. " 
 
 The following varieties of cystic tumours are met with : — 
 Cystic fibromyoma or fibrocystic tumours. — These are 
 fibromyomata, in which collections of fluids have formed. 
 In some cases, myxomatous or colloid degeneration of the 
 connective tissue between the muscular bundles is the 
 starting-point of the condition, or an oedematous infiltra- 
 tion ; there are no distinct walls in the cysts formed, as 
 
 they are formed simply as 
 lacunar in the tissue of the 
 tumour itself. 
 
 In other cases cysts may 
 be formed as the result of 
 dilatations of lymphatics, the 
 so-called fibrojnyoma lymphan- 
 giedodes. The cysts are usually 
 lined with endotheliuni, 
 though this may not be easily 
 distinguished in large ones. 
 The fluid coagulates spon- 
 taneously on exposure to air. 
 Sometimes there may be, as well, a condition of dilatation 
 of blood Q.di'^'^2iaQ.':>— fibromyoma telangiectodes. 
 
 Sarcomatous degeneration may sometimes produce a cystic 
 condition. Hemorrhages may take place into cysts in all 
 the above-mentioned varieties, causing them to increase 
 in size. Rupture into the uterine cavity may sometimes 
 take place. 
 
 If the cervix be obliterated, as is sometimes the case 
 in women after the menopause, the cavity of the uterus 
 may be gradually distended, forming a large blood 
 collection. \ 
 
 The great majority of these cystic conditions are found in 
 subperitoneal fibroids. They may grow rather quickly, and 
 form masses of very large size. 
 
 Fig. 179. — Ordinary cystic form 
 of a fibromyoniatous uterus. 
 
 i ! 
 
 f\ 
 
CYSTIC TUMOURS. 
 
 501 
 
 Cystic adenomyoma. — These are fibromyomata in which 
 cysts are found lined with cylindrical epithelium. They 
 have been chiefly described by von Recklinghausen and 
 Freund. They occur at the junction of the tube and 
 uterus. (Similar growths are found in connection with the 
 tube alone.) They develop in the muscular part of the 
 wall, and may extend outwards to the peritoneum or into 
 the broad ligament; they may thus infiltrate surrounding 
 tissues diffusely, thus differing from pure fibromyomata. 
 
 Fig. 180. — Cystic adenomyoma. — Von Rixklinghau'skn. 
 
 V. Anterior uterine wall. 
 
 D. Posterior uterine wall, 
 
 /. Collection of small gland-like spaces in the tumour. 
 
 R. Rectum. 
 
 Ad. Adhesions. 
 
 S. Mucous membrane of utert s. 
 
 Vag: Vagina. 
 
 They tend to form adhesions. Von Recklinghausen classifies 
 the tumours as follows : — 
 
 I. Hard masses in which the adenomatous development 
 is scanty. 
 
V 
 
 502 
 
 FIB ROM YO MA UTERI. 
 
 / 
 
 2. Those in which many small cysts are discoverable by 
 the microscope. 
 
 3. Soft masses in which cysts of various sizes exist, which 
 can be seen by the naked eye. 
 
 4. Very soft telangiectatic growths in which adenomatous 
 tissue is present, but few or no cysts. 
 
 He believes that these growths are developed from relics 
 of the Wolffian bodies which have remained in the uterine 
 wall. 
 
 He also describes a rare form of cystic adenomyoma, 
 which is distinguished by its intimate connection with the 
 
 uterine mucosa. Its adeno- 
 matous structure resembles 
 that "of the mucous mem- 
 brane, and a number of 
 depressions pass from the 
 latter into the tumour. 
 
 These tumours are less 
 apt to form peritoneal ad- 
 hesions than the other var- 
 iety. They are apt, however, 
 to become carcinomatous. 
 
 Freund has arranged the 
 symptoms of cysto-adeno- 
 myomata as follows : — There is often a history of poor 
 health in childhood. Menstruation appears late. Menor- 
 rhagia and dysmenovrhcea are very constant. Sterility is 
 common. The general health gradually fails. The external 
 genitals and vagina are usually undersized. 
 
 Blood cyst of the uterine wall. — In 1895 I described 
 an interesting case in which a large unilocular blood cyst 
 developed from the wall of the uterus, three years after the 
 menopause. The patient in whom it occurred first noticed 
 the swelling about a month after she had strained herself 
 severely, pelvic pains being set up. In five months' time, 
 great distension of the belly was caused. 
 
 Fig. 181. — Section of a cystic adeno- 
 myoma of the uterus. 
 
CYSTIC TUMOURS. 
 
 503 
 
 The cyst wall was deeply congested, contrasting with the 
 pale uterus. It had elongated the fundus into a kind of 
 pedicle. 
 
 The cyst wall varied in structure. The fibrous tissue 
 predominated over the muscular, and in many places was 
 dense and sclerosed ; in many places the muscle was 
 atrophied. Throughout the wall many dilated capillaries 
 were found. The cavity contained blood, granular debris, 
 flakes of fibrin, and a few cholesterin crystals. In the 
 elongated fundus, which was largely 
 composed of connective tissue and 
 atrophying muscular bundles, a collec- 
 tion of cavities containing blood was 
 found, about the size of a walnut ; 
 it resembled an angioma, and seemed 
 to consist of dilated capillaries. No 
 sign of a myoma was seen anywhere 
 in the wall. 
 
 I believe that this tumour arose 
 from an angiomatous condition of the 
 fundus, the sudden strain which the 
 woman made leading to a rupture of 
 the wall of one of the blood spaces, 
 and to a gradual accumulation of 
 blood, slowly poured out, forming a 
 large blood cyst. 
 
 Diagnosis of these various cystic conditions. — The 
 symptoms are much the same as in the case of fibroids, 
 except that usually they develop more quickly. As most 
 are subperitoneal, there may often be no menstruation 
 disturbar.ces. On physical examination, the conditions 
 found in fibroids are present, except that in addition cystic 
 characters are made out. But, as I have already said, a 
 soft myoma may simulate a cyst in character. Cystic 
 fibroids are more apt to become gangrenous, and to develop 
 thrombosis, than solid tumours. 
 
 Fic. 182. — Large blood 
 cyst of the uterus. The 
 fundus uteri is elong- 
 ated, and contains a 
 mass of distended 
 blood spaces. 
 
 i 
 
V 
 
 504 
 
 FIBROMYOMA UTERI. 
 
 Differential diagnosis of cystic tumours : — • * 
 
 1. From soft myoma. * 
 
 2. From ovarian tumours. 
 
 3. From a fibroid with pregnancy. 
 
 Treatment. — In these cases the procedure varies, accord- 
 ing to the extent of the cystic formation. If there be one 
 pediculated cyst, it is removed just au is a subperitoneal 
 fibroid. If the cystic disease is extensive, amputation of 
 the uterus or panhysterectomy should be performed. To 
 make the mass as small as possible the cysts may be tapped 
 before removal is carried out. 
 
 ••*if>r 
 
 w 
 
 ^ \ 
 
 s\ 
 
\ 
 
 CHAPTER XVII. 
 
 CARCINOMA UTERI. 
 
 Primary carcinoma may develop either in the body or in 
 the cervix uteri. In about 98 per cent, of cases, the latter 
 is the seat of the disease. 
 
 Vv 
 
 Carcinoma Cervicis Uteri. 
 
 Etiology. — In women the cervix uteri is the most frequent 
 seat of cancer ; the breast comes next in order. The 
 majority of cases of carcinoma uteri are met with betw en 
 40 and 50. The following table of Gusserow, in whicti 
 3471 cases are analysed, is interesting: — 
 
 Carcinoma uteri developed at the age of — 
 
 17 years m i case 
 
 20-30 „ 114 „ 
 30-40 „ 770 .. 
 
 40-50 years in 1 196 cases 
 50-60 „ 856 ,, 
 60-70 „ 340 ,, 
 Above 70,, 193 ,, 
 
 The disease has been reported earlier even than 17; in a 
 case of Ganghoffer at 9. 
 
 Hereditary predisposition is believed to play some part 
 in its production. It seems to be more common among 
 the poor and unhealthy than among the well-to-do and 
 strong. 
 
 Race is a factor to be considered. The disease is rare 
 among black women. Lacerations and inflammations are 
 predisposing causes ; consequently it is mainly found in 
 married women. 
 
V 
 
 So6 
 
 CAKCLVOMA UTERI. 
 
 a^P^ 
 
 Pathology. — It is impossible to speak with accuracy re- 
 garding the various modes of origin of cancer, or to establish 
 a satisfactory classification of them as they occur in the 
 uterus. It is probable that all forms arise solely from 
 epithelium. They may, therefore, be divided into those 
 which originate from cylindrical^ and those starting from 
 squafnous epithelium. The former are the most frequent. 
 As to the portion of the cervix in which the disease most 
 commonly begins, Hofmeier states that of 422 cases, 236 
 began ^i the portio, and 186 higher up in the cervix. 
 
 Of the cylindrical-cell cancers, those of the medullary type 
 
 are more common than ihose of 
 scirrhous type. 
 
 As regards the squamous-celled 
 variety, the origin is in almost all 
 cases the covering of the portio 
 vaginalis ; very rarely it may grow 
 from the interior of the cervix, 
 or, as we shall see later, from the 
 mucosa of the corpus uteri. I 
 have already pointed out that 
 papilloma covered with squamous 
 epithelium may spring from the 
 mucosa internal to the os exter- 
 num, and it is possible in these 
 cases that there may be an 
 abnormal covering of the lower part of the cervical lining 
 with squamous epithelium. 
 
 It is difficult to draw a distinction between the simple 
 and malignant growths. Transition forms may sometimes 
 be seen in the same growth. Thus the papilloma may be 
 for a time simple and then may take on an epitheliomatous 
 character. So, also, transit on forms may be seen between 
 an adenomatous growth in the mucosa and the distinct 
 cylindrical-celled cancer. Thus in the latter may be seen 
 gland-like spaces lined with a single layer of cells, others 
 
 Fig. 183. — Early epithelioma 
 of vaginal portion of cer- 
 vix. A cell nest is seen, 
 surrounded by small cell 
 infiltration. 
 
 \ \ 
 
PATHOLOGY. 
 
 507 
 
 lined with two or more layers, and others in which there 
 is no lumen whatever. Sometimes, small masses of epi- 
 thelium project into the lumen. The cancerous cells next 
 the connective tissue are 
 usually cylindrical and 
 perpendicular to the 
 surface ; those more in- 
 ternal are of irregular 
 shape and sizes, the cen- 
 tral ones being easily 
 detached. The cells 
 multiply chiefly by in- 
 direct nuclear division, 
 like the normal cells. 
 The nuclei are larger, 
 
 Fig. 184. — Carcinoma cervicis. 
 Medullary form. 
 
 more abundant in chromatin, and more often originate 
 karyokinetic figures than the normal cells. Asymmetrical 
 
 and multipolar mitoses have 
 been described by seveial as 
 taking place exceptionally fre- 
 quently in the cancer cells. 
 Often more than one nucleus 
 is present, and their chroma- 
 tin tends to be shed into the 
 surrounding protoplasm before 
 division (Roger Williams). 
 These appearances indicate 
 
 „ ^, . marked reproductive activity. 
 
 Fig. 185. — Carcmoma cervicis ^ •' 
 
 uteri. The cancerous cells are The cancer cells may undergo 
 
 seen extending irregularly muCoid, CaseOUS, fatty, Or cal- 
 
 among the tissues of the wall, careous degeneration ; colloid 
 
 not being in well-defined , . , 
 
 groups. changes or pigmentary changes 
 
 are rare. 
 
 Ivcucocytes may wander between the cells and may enter 
 
 them. 
 
 In some cases of rapidly growing carcinoma, the epithelial 
 
 Xv 
 
 11 
 

 V 
 
 m I 
 
 I 
 
 So8 
 
 CARCINOMA UTERI. 
 
 cell masses may spread out irregularly into the tissues as is 
 sometimes the case in rapid mammary cancer. 
 
 The connective tissue stroma of the new growth is cellular 
 mainly ; in some cases it is partly or wholly myxomatous in 
 nature. 
 
 In examining specimens microscopically, it is important 
 to avoid errors of interpretation. Thus oblique sections of 
 normal glands must not be regarded as cancerous alveoli ; 
 this mistake is especially apt to be made if the fundus of 
 
 Fig. i86. — Car- 
 cinoma cervi- 
 cis. The cervix 
 is being exca- 
 vated internal 
 to the OS ex- 
 ternum. 
 
 Fig. i88.— Car- 
 cinoma cervi- 
 cis. Cauli- 
 flower - like 
 growth of 
 vaginal por- 
 tion of cervix. 
 
 Fig. 187. — Car- 
 cinoma cer- 
 vicis. The 
 disease has 
 partly de- 
 stroyed the 
 cervix, and has 
 spread to the 
 vaginal walls. 
 A vesico-vagi- 
 nal fistula has 
 been formed. 
 
 the gland be cut across. Serial sections alone can decide 
 regarding such points as these. The arrangement of the 
 cells is important — regular and orderly in normal conditions, 
 irregular in shape, size, and arrangement in cancer. In the 
 latter, also, it is important to note the frequency of mitoses. 
 The small round-cell infiltration of the stroma resembles, 
 greatly, inflammatory tissue. Moreover, in inflammatory 
 conditions, the glands may be compressed so that the 
 lumina are destroyed, and the epithelium compressed and 
 
 |\ 
 
PATHOLOGY. 
 
 509 
 
 flattened, so that there may be a strong resemblance to the 
 projections of early rapidly growing cancer. 
 
 Note. — Plimmer emphasises the importance of the use of congo-red 
 (i per cent, aqueous soUition) as a cell-substance stain, best employed 
 with ha-matoxylin as a nuclear stain. Normal gland epithelium is 
 stained strongly red ; cancer cells remain almost unstained. 
 
 Clinically, cancer may be observed to start in the cervix 
 as follows : — 
 
 1. As a fungating epitheliomatous growth from the 
 vaginal surface. This usually spreads out to the fornices, 
 may eat deeply into the cellular tissue, and may sometimes 
 spread up the cervical canal. 
 
 2. As one or more nodules, superficially or deeply placed 
 in the mucosa lining the canal, or bulging outwards toward 
 the vaginal surface of the cervix. As growth takes place, 
 ulceration of the mucosa lining the canal or covering the 
 vaginal portion over it occurs, and infiltration of surrounding 
 tissues. It may spread to the corpus uteri. Sometimes, in 
 cervical cancer, nodules of the disease may be found in the 
 body, though there is no direct continuation of the growth. 
 This may possibly take place through lymphatic transmis- 
 sion. Seelig states that the lymphatic communication 
 between body and cervix is much freer in the muscular part 
 of the wall than in the mucosa, on account of the larger 
 size of the lymphatics. Possibly in some of these cases 
 the upper growth may be primary, that in the cervix 
 being due to direct implantation of a portion of the 
 tumour. 
 
 3. As an infiltration which tends to spread superficially 
 around the mucosa of the canal eroding it. This may take 
 place to a considerable extent, while the vaginal portion of 
 the cervix and the os externum appear from below to be 
 perfectly normal. This form tends to spread early to the 
 corpus uteri, then to the parametric tissues ; last of all, or 
 not at all, to the vagina. 
 
 
 f.5 
 
v., 
 
 510 
 
 CARCINOMA UTERI. 
 
 Exiension. — The growth spreads by the lymphatics, or by 
 a continuous chain of infiltration of the connective tissue. 
 
 The broad and utero-sacral ligaments may become affected. 
 The ureters are often involved by pressure or by spread 
 of the disease to their walls ; as a consequence, dilatation, 
 hydronephrosis, and atrophy of the kidney substance result. 
 
 It may spread to the wall of the bladder, causing first a 
 vesical catarrh ; then portions may slough, so that perforation 
 may be brought about. Then inflammation may spread to 
 the ureter and kidney ; in the latter, interstitial nephritis, 
 pyelitis, or pyelonephritis may result. Sometimes only dila- 
 tation of the ureters and hydronephrosis are produced. 
 It appears that cardiac hypertrophy attends renal lesion in 
 cancer very rarely — probably where the disease is of rapid 
 development (LetuUe). \ 
 
 Rarely does the cancer extend backwards and attack or 
 open the rectum. Sometimes both bladder and rectum 
 may be opened, so that the vagina may be converted into 
 a kind of cloaca. 
 
 Perforation of the peritoneum is rare, because, as the 
 cancer spreads towards it, inflammation is set up, thicken- 
 ings and adhesions being formed. 
 
 The mucosa of the uterus not directly affected is often in 
 a state of hyperplastic endometritis, and it may sometimes 
 show a tendency to malignancy (according to Abel, in the 
 direction of sarcomatous change, in some cases). 
 
 Metastases may develop in liver, kidney, stomach, lungs, 
 etc. The hypogastric, iliac, sacral, and lumbar glands may 
 be involved ; the inguinal also in some cases, even where 
 there is no vaginal affection. This is due to a communica- 
 tion which exists between the hypogastric and inguinal glands, 
 by means of the gland of Guerin ; also to that which exists 
 between the uterine lymphatics and the groin by way of the 
 round ligament. Troiser has pointed out how prone are 
 the left subclavicular glands to become affected. When 
 there is a bad ulcerating surface, from which septic 
 
 i\ 
 
LOCAL SYMPTOMS. 
 
 5" 
 
 matter is absorbed, the liver tends to undergo fatty 
 degeneration. 
 
 Local symptoms. — The disease is usually quite insidious at 
 first. It may be considerably advanced before the patient 
 notices that anything is wrong. 
 
 Haemorrhage is generally the first noted symptom. It 
 may be a mere trace noticed after coitus, defaecation, or 
 some other form of exertion. In these cases probably the 
 blood comes from the hypertrophied mucosa near the 
 tumour. Sometimes it arises from ulceration. Sometimes 
 the menstrual period is noticed to be rather profuse. 
 Metrorrhagia may develop. In the late stages of the 
 disease, haemorrhage is not prominent, unless a large vessel 
 should be ulcerated through. 
 
 Leucorrhoea is a prominent feature usually. At first this 
 has the ordinary characters found in connection with endo- 
 metritis. In the papillary form there is an early profuse 
 watery discharge. 
 
 When ulceration has occurred, and the cancer has begun 
 to break down, the characteristic discharge with its foul 
 smell is produced. It is variously coloured, being yellowish 
 white, brown, green, or bloody. It is made up of serum, 
 mucus, broken-down tissue in a state of necrosis or fatty 
 degeneration, pus cells, more or less blood, colonies of 
 micro-organisms. 
 
 Pain is often present in cancer; in some cases it is 
 hardly ever noticeable throughout the whole progress of the 
 disease. It rarely occurs in the first stage, but rather later, 
 when infiltration of the uterine wall and of the parametric 
 tissue is taking place. When branches of the sacral plexus 
 are involved, the pain may be very intense. It is often 
 improved when much breaking down of the growth occurs. 
 
 The pain varies in character ; it may be felt in the lumbar 
 regions, in the pelvis, and shooting down the legs. It is 
 dull and gnawing, or sharp and cutting. Sometimes the 
 pains met with are mainly due to peritonitis, when there is 
 
 M 
 
 m 
 
 j I 
 
V 
 
 519 
 
 CARCINOMA UTERI, 
 
 usually rigidity of the abdomen and tenderness on pal- 
 pation. Various reflex and sympathetic pains are often 
 found, e.g. in the mammoe. White swelling may be found 
 in the lower limbs. 
 
 General symptoms. — In the early stages the patient may 
 show no sign of ill-health. Gradually reflex phenomena 
 appear, e.g. disturbance in the digestive tract ; and as the 
 disease advances, anorexia, constipation, meteor m, etc., 
 become marked. 
 
 The patient gets weaker and loses flesh. Then the so- 
 called " cancerous cachexia " develops. The skin gets yellow, 
 probably due to coprcemia, and it is also usually harsh and 
 dry. There may be cystitis and micturition troubles or 
 difficulty on defcecation. If fistulae are present, the dis- 
 charges pass per vaginam. Staining and itchiness of the 
 >'ulva may be produced by the discharges. ' 
 
 In some cases there are periodical attacks of subacute 
 uraemia. As the disease progresses this tends to become 
 chronic, and the patient becomes dulled in intelligence and 
 sensibility. Towards the end, a semicomatose condition 
 often develops, during which no pain may be felt. 
 
 Death may occur quietly during one of these attacks. 
 Uraemia with convulsions is not often met with. Death 
 from peritonitis or perforation is rare. The latter and 
 embolism may cause sudden death. Often death may be 
 alone due to the general blood poisoning. Sometimes 
 death occurs from haemorrhage, sometimes as a result of 
 venous thrombosis. 
 
 Physical signs. — In the very early stages ihe disease is 
 seldom made out, simply because patients rarely come to 
 the physician (owing to the absence of symptoms) before 
 the affection has advanced somewhat. 
 
 When cases are seen, either a hardness may be felt on 
 the vaginal portion of the cervix or inside the os externum ; 
 it is sometimes felt raised above the surface, an ulcerated 
 surface may be felt, or a cauliflower growth distinguished. 
 
DIFFERENTIAL DIAGNOSIS. 
 
 S»3 
 
 icks. 
 
 eath 
 and 
 be 
 mes 
 t of 
 
 on 
 
 im; 
 
 lated 
 
 Ihed. 
 
 On examination through the speculum, these conditions 
 may be seen. Stratz states that the non-ulcerated cancer 
 is very yellow and brightly granular. 
 
 In the late stages the diagnosis is usually easier. The 
 hardness of the growth and infiltrations is felt. The 
 fingers have a very bad odour from the discharge. 
 
 In cases where the cervical mucosa is being eroded, the 
 OS externum may, on vaginal examination, appear normal. 
 On dilating it, however, the excavation within is recognised. 
 Rectal examination is very important, especially in deter- 
 mining whether or not the uterus is fixed, and to what extent 
 the disease has spread beyond the organ. There is no means 
 of knowing definitely whether the latter change has occurred. 
 
 Ordinarily it is taught that if no hard infiltration is felt 
 external to the uterus, and if it be freely movable, the 
 disease has not spread beyond the uterus. This is, how- 
 ever, fallacious. There may be a delicate lymphatic in- 
 fection, not marked enough to fix the uterus, or to be felt 
 by the finger. (Old cellulitis or peritonitis must not be 
 diagnosed as infiltration.) There is usually some bleeding 
 after examination. 
 
 In forming an opinion it is important to cut out a piece 
 of the tissue for careful microscopic examination. 
 
 Differential diagnosis. — Carcinoma cervicis must be dis- 
 tinguished from the following : — 
 
 1. Hypertrophy of the cervix. 
 
 2. Endocervicitis with catarrhal patches on the vaginal 
 portion, and Nabothian follicles. 
 
 3. Cervical polypus. 
 
 4. Ulcerating or sloughing fibroid polypus. 
 
 5. Syphilitic ulceration and condyloma of cervix. 
 
 6. Retained bits of placenta and membranes, especially if 
 decomposition has taken place in them. 
 
 7. Sarcoma, fibroid or papilloma of cervix. 
 
 8. Diphtheritic patch. 
 
 9. Lupoid ulceration. "" 
 33 
 
 ! ': 
 
 » 1 
 
 'in 
 
 i ': 
 
V 
 
 514 
 
 CARCINOMA UTERI. 
 
 Y 
 
 Prognosis. — The average duration of the disease is one 
 to two years. It may be less or more. Early in life the 
 disease usually advances more rapidly than it does in later 
 years e.g. at the menopause. 
 
 The scirrhus and the epithelioma have a longer duration 
 than the encephaloid. The scirrhus may last for several 
 years in some cases. 
 
 Treatment. — The only means of radical cure is by removal 
 of the disease. This can only be done when the disease is 
 limited to the cervix. 
 
 When the disease has not spread beyond the cervix, 
 two operations are employed for its removal, namely, high 
 amputation of the cervix above the limit of the cancer, 
 and total vaginal extirpation of the uterus. Both of these 
 methods have been followed with success, but the tendency 
 at present is to limit the former of them to a very small 
 number of cases, e.g. those in which it is definitely certain 
 that the disease is very early, strictly limited, and capable of 
 being removed by a high amputation. In all other con- 
 ditions, and especially in cases of doubt as to the extent of 
 the disease, ex irpation of the uterus should be performed. 
 
 High amputation. — The circular method is employed, the 
 operation being carried out as already described. 
 
 Vaginal extirpation. — This can only be carried out when 
 the vagina is not too small. If more room be desired in 
 any case, the vagina should be distended with Barnes bags 
 two or three days previous to operation. Sometimes during 
 the operation it is well to divide the perineum on each side 
 of the middle line in order to obtain more room. These 
 wounds can be closed at the end of the operation. 
 
 The patient is prepared for the operation as described on 
 p. 249. Great care must be taken to destroy all sources of 
 septic infection by antiseptic douchings and packings with 
 gauze. The patient is placed in the lithotomy position, the 
 bladder and rectum being empty. The vagina is stretched 
 by means of short anterior and posterior spatular specula, 
 
 f \ 
 
TREATMENT. 
 
 515 
 
 and lateral retractors. The cervix is drawn downwards and 
 forwards, and held with a volsella by an assistant. 
 
 The surface of the diseased portion should be carefully 
 cleansed of all discharge, and should be thoroughly swabbed 
 with turpentine, and then with a solution of zinc chloride. 
 Any portion which is breaking down, or is apt to be broken 
 down during the operation, should be removed with a 
 curette, the raw surface being burned with a galvano-cautery, 
 or touched with a strong sol-ition of perchloride of iron. 
 
 Fig. 189. — First stage in the operation of vaginal extir- 
 pation of the uterus. Opening into the pouch of 
 Douglas. — A. Martin. 
 
 The pouch of Douglas is then opened by a transverse 
 incision through the junction of the posterior vaginal wall 
 and cervix. Bleeding points on the uterus are tied. It is 
 checked on the vaginal flap by means of a continuous 
 suture, which brings together the edges of the peritoneum 
 and vaginal mucosa. 
 
 
 '■»' 
 
V 
 
 Si6 
 
 CARCINOMA UTERI. 
 
 The utero-vesical pouch is then opened, thie cervix 
 being pulled downwards and towards the back. A trans- 
 verse incision is made through the junction of the anterior 
 wall and cervix as deep as the uterine musculature. The 
 bladder is then stripped upwards from the cervix, and 
 the utero-vesical layer of peritoneum is cut across trans- 
 versely. Then the cut edge is united to the edge of the 
 anterior vaginal wall by catgut suture, thus covering the 
 back of the bladder. The broad ligaments now remain to 
 be secured and divided. At this stage the pelvis should 
 be explored with a finger, and uterine adhesions broken 
 down. To secure the ligaments the ligature method or the 
 clamp method may be used. 
 
 {a) Ligature method. — Strong silk ligatures are passed 
 by means of a curved pedicle needle through the broad 
 ligament on each side, a short distance out from the uterus, 
 the forefinger being passed into the peritoneal cavity to guide 
 the needle. The lowest ligature should secure the uterine 
 artery, and should not embrace the ureter. The higher the 
 passing of the ligatures in the broad ligament, the farther out 
 from the uterus these may be placed. As each one is tied, the 
 ligament is divided internal to the knot by means of scissors. 
 
 If, during the operation, the intestines tend to prolapse 
 and interfere with the manipulations, they may be kept up 
 by an iodoform gauze pad placed in the pelvis. 
 
 If the tubes and ovaries come down easily, they may also 
 be removed, but it does not matter if they be partly left 
 behind. When the uterus is removed the pelvic cavity may 
 be washed out. Ligature ends are then brought down into 
 the vagina, those of each side being tied in a bundle. Some 
 operators use catgut ligatures (No. 4). In such a case the 
 ends may be cut short. They should not reach so far as 
 the vulva. 
 
 If a very wide opening remain in the vaginal roof, it can 
 be made smaller by means of a catgut suture. But there is 
 no necessity for closing it entirely. A plug of iodoform 
 
 / ' 
 
 W 
 
TREATMENT. 
 
 5»7 
 
 gauze should be carefully placed against the fornix. If 
 there has been oozing in the pelvis, a portion of gauze 
 should be passed through the opening to act as a pelvic 
 drain. 
 
 After-treatment. — The patient lies in bed, and is treated 
 generally as after an abdominal section. The urine is 
 drawn off every six hours for five days, and thereafter the 
 patient passes water at regular intervals. On the day follow- 
 ing the opc-ation the gauze plug should 
 be removed from the vagina if there has 
 been much oozing from the pelvis. If 
 there has been only a little discharge, it 
 should not be taken away until the third 
 day. Thereafter the vagina should be 
 douched daily with a double catheter, a 
 solution of formalin (i in 4000) being 
 used. After each douche an iodoform 
 pessary should be passed into the vagina. 
 
 Between the second and third weeks 
 the ligatures usually begin to drop off. 
 Sometimes undue retention of a ligature 
 is associated with rises in temperature. If 
 they are not all away by the eighteenth 
 or twentieth day, the patient should be 
 placed in the lithotomy position, and they jj^> 
 should be carefully removed. 
 
 Grad has recently introduced a method 
 whereby the silk ligatures may be easily 
 removed. Traction-strings are included in each knot of the 
 ligatures, as figured in the diagram, the strings being marked 
 by the number of knots put upon them. The mass of 
 strings and ligatures are left in the vagina. 
 
 The removal of the ligatures may be carried out on the 
 fourth or fifth day, or on the third, fourth, and fifth days. The 
 patient is placed in the lithotomy position, and the ends of 
 the ligatures and traction-strings carefully distin-^uished. 
 
 Fig. 190. — Grad 
 ligature. 
 
 W' 
 
 1 
 
 n 
 
5i8 
 
 CARCINOMA UTERI. 
 
 / 
 
 Traction-string No. i is then gradually pulled on, each 
 half alternately until it comes away, indicating tha. .:not 
 No. I is untied. The same manoeuvres are carried out 
 with the other traction-strings until the whole ligature is 
 left untied. It may then be pulled away. Catgut sutures, 
 as a rule, give no trouble. 
 
 (p) Clamp method. — The clamp used is a pair of long 
 forceps, with a separable lock. At the handles there is a 
 catch, with whicb they can be held together. When the 
 anterior and posterior peritoneal pouches are opened, the 
 forceps are placed on the broad ligaments, embracing their 
 whole extent, and the uterus is cut away internal to them. 
 When it is impossible to secure the ligament by one clamp 
 on each side, the lower half of the ligament is clamped on 
 each side, the corresponding part of the uterus being cut 
 free. The uterus can then be pulled down, so as to allow 
 of the application of forceps to the rest of the ligament. 
 The whole uterus is then removed. The handles of the 
 forceps are tied, to prevent them from opening. A plug 
 '^f iodoform gauze is placed in the fornix, and the handles 
 of the forceps are kept from pressing unduly against the 
 vaginal walls by gauze pads. The patient is then placed 
 in bed. 
 
 After-treatment. — In general the same as that just de- 
 scribed. The forceps are carefully removed from thirty to 
 forty hours after the operation, and an iodoform gauze plug 
 is placed in the vagina. After three weeks the patient 
 should rise. 
 
 The clamp operation is more quickly carried out than the 
 ligature method. It is held to be more convenient when 
 perimetritis or parametritis makes it difficult to draw the 
 uterus down. 
 
 The dangers connected with vaginal extirpation are after- 
 hsemorrhage, sepsis, injury to bladder, ureter, or intestine. 
 
 The Richelot- Doyen method {^ide p. 359) may also be 
 employed, but only when the operator can be sure that the 
 
 •\ 
 
// 
 
 TREATMENT. 
 
 519 
 
 splitting of the uterus will not lead to the detachment of 
 cancerous nodules, which might give rise to a fresh 
 infection. 
 
 Abdominal hysterectomy. — If, on account of the size of 
 the vagina, the vaginal method be impossible, the abdominal 
 method should be employed. It is very rarely required. 
 The method is described in connection with .uyoma uteri. 
 
 From statistics it is impossible to decide whether in a 
 
 'm. 
 
 '^m 
 
 
 Fig. 191. — Vaginal extirpation of the uterus. Clamp method. 
 Application of clamps to broad ligaments. — Pean. 
 
 Strictly localised cancer of the cervix the high amputation or 
 total extirpation is to be preferred. The present tendency 
 is in favour of the latter. Certainly there should be no 
 hesitation to employ the more extensive operation when the 
 disease is situated in the upper part of the cervix, or is 
 excavating the cervical mucosa. 
 
 In deciding on the operation, the condition of the urine 
 
■v. 
 
 520 
 
 CARCINOMA UTERI. 
 
 should be carefully examined. If there is much solid matter 
 in it, operation must be postponed or put off altogether, 
 owing to the great risk of uraemia and shock. 
 
 Where there is any imperfect secretion the patient should 
 be placed on milk for some days before operation, and 
 should be kept on this diet for some time afterwards. 
 
 Cancer of the Cervix too Advanced for 
 Complete Removal. 
 
 In many cases, instead of allowing the disease to follow 
 its own course, it is advisable to carry out certain measures 
 of a palliative nature, in order to keep the patient in as 
 comfortable a condition as possible. 
 
 For sharp haemorrhage, plugging of the vagina for two or 
 three days with iodoform gauze is the best remedy. To keep 
 down the offensive discharge various douches may be used, 
 e.g. solution of potassium permanganate, corrosive sub- 
 limate, iodic hydrarg., etc. After the douche a mixture 
 of equal parts of glycerin and olive-oil should be injected 
 into the vagina, and the vulva lubricated with the same 
 mixture. 
 
 To destroy the superficial portions of the growth, the 
 following means may be used : — 
 
 Curettage with application of the cautery or caustic. — 
 The carcinomatous tissue is scraped out with a spoon curette, 
 care being taken not to perforate the uterine wall. Bleed- 
 ing is checked by the application of an iodoform gauze 
 plug to the scraped surface for a few minutes. When it is 
 removed the ball-point of Paquelin's cautery is applied at 
 a dull red heat. 
 
 An iodoform gauze plug is then placed in the cavity and 
 in the vagina for two days. Afterwards a daily antiseptic 
 douche is used. 
 
 Instead of the cautery, pledgets of wool soaked in a 50 
 per cent, solution of zinc chloride may be placed against 
 the raw surface. These are covered with a dry piece of 
 
 \\ 
 
// 
 
 CANCER OF THE CERVIX. 
 
 521 
 
 wool, and below, a plug of iodoform gauze, soaked in a 
 saturated solution of sodium bicarbonate, is placed. 
 
 After eight or nine days the plugs are removed, and the 
 surface of the cancer comes away as a slough. Iodoform 
 gauze is then packed in the cavity for a couple of days, and 
 is followed afterwards by antiseptic douches. 
 
 Amputation of as much of the cervix as possible. — This 
 may be carried out by the methods already described 
 
 (P- 438). 
 
 The ^craseur or galvano-caustic wire may also be used 
 
 for this purpose. The patient is placed in the lithotomy 
 
 position, the vagina opened with specula, the cervix held 
 
 with a volsella, and the chain or wire is then placed around 
 
 it. The amputation should proceed very slowly. If there 
 
 is bleeding afterwards, the points should be touched with 
 
 the Paquelin cautery, and an iodoform gauze plug placed in 
 
 the vagina for five or six days. 
 
 General measures. — Pain must be relieved with mor- 
 phine; if trional be used with this drug, small quantities 
 will often suffice. Phenacetin or codein in powder is 
 also most satisfactory. 
 
 The digestion should be carefully looked after and the 
 bowels kept regular. A diet containing vegetables and 
 fruit, e.g. prunes, roast apples, etc., is valuable; laxatives 
 may, however, be required. Usually a daily enema con- 
 taining an ounce of glycerin acts satisfactorily. 
 
 The patient should sleep in a well-ventilated room, 
 should be placed in cheerful surroundings, and be free 
 from worries and cares. 
 
 In bad a piece of thin waterproof sheeting tied around 
 the body keeps down the bad odour, and in the day a 
 petticoat of similar material should be worn. Sexual 
 intercourse should be abandoned. The skin around the 
 vulva is to hi protected by vaselin, olive-oil, and glycerin, 
 or olive-oil and lime-water. 
 
 
 ^ ^1 
 
 '5 1 
 
 i -A\ 
 
V. 
 
 522 
 
 CARCINOMA UTERI. 
 
 Carcinoma Corporis Uteri. 
 
 Pathology. — Cancer of the body occurs in less than 2 
 per cent, of all cases. It is more frequent in nulliparje than 
 carcinoma cervicis, and tends to occur rather later in life 
 than cancer of the cervix. 
 
 The disease begins superficially or deeply in the mucosa. 
 Epithelioma, malignant adenoma, adeno-carcinoma, and 
 pure carcinoma are found, the latter being of the scirrhous 
 or medullary type. 
 
 In the malignant adenoma there is an atypical prolifera- 
 tion of the glands ; they be- 
 come folded up irregularly ; 
 the intervening connective 
 tissue may be very scant, 
 and the gland spaces may 
 touch at points. They are 
 lined with a single layer of 
 columnar epithelium. 
 ^ . , . , , In the adeno-carcinoma, 
 
 Fig. 192. — Carcinoma of body of 
 
 uterus. Simple gland spaces, P^rts may show the Structure 
 spaces in which the epithelium is of the malignant adenoma, 
 proliferating, and another com- ^nd parts that of the ordinary 
 
 pletely filled with carcinomatous , 1 1 t 
 
 cells, are shown. cancer where the loculi are 
 
 filled with epithelial cells. 
 
 These growths form swellings in the wall. When near 
 the cavity, the mucosa may ulcerate over them. Gradually 
 the uterus becomes excavated. Adhesions may form with 
 adjacent structures, and secondary deposits develop in the 
 peritoneum, ovaries, tubes, vagina, etc. 
 
 The epithelioma may grow diffusely through the whole 
 cavity, or as an isolated fungoid growth, which may become 
 polypoidal. v 
 
 Metastatic nodules may form in different parts of the 
 uterine wall. These tumours are covered with layers of 
 polyhedral cells ; very rarely pavement epithelium is found 
 
CARCINOMA CORPORIS UTERI. 
 
 523 
 
 like that in an ordinary epithelioma. The mucosa of the 
 body gets thinned. 
 
 When the disease develops in the puerperium it runs a 
 rapid course. 
 
 Symptoms. — These are much the same as in cancer of 
 the cervix. Pain is a more early symptom as a rule. 
 Often it occurs in very severe paroxysms, probably due to 
 infiltration of the dense wall in various directions, or some- 
 times to the accumulation of secretion in the cavity, the 
 uterus endeavouring to expel it. Haemorrhage also usually 
 occurs early. 
 
 Physical signs. — Bimanually, the uterus is felt to be 
 enlarged and movable, 
 unless fixed by ad- 
 hesions. The cervix 
 may be closed, but it 
 is often softened and 
 somewhat dilated. On 
 exploring the cavity 
 with a finger, the ir- 
 regularities, hard 
 masses, and fungosi- 
 ties may be felt. These 
 may be detected with 
 a sound, but the in- 
 strument must be used 
 most cautiously. 
 
 It may be necessary to curette the cavity and to 
 examine the fragments microscopically. It may be 
 difficult to decide between a hyperplastic endo- 
 metritis and an adenoma. Several portions should be 
 examined. 
 
 Sometimes it may be impossible to decide as to the 
 nature of the case, and, in such a case, it may be necessary 
 to recommend extirpation of the uterus when the diagnosis 
 of cancer is only a probable one. 
 
 Fig. 193. — Carcinoma of the body of the 
 uterus. Large spaces are shown nearly 
 filled with carcinomatous cells. 
 
524 
 
 CARCINOMA UTERT. 
 
 \ 
 
 The differential diagnosis lies between — ( 
 
 1. Haemorrhagic endometrtis. 
 
 2. Simple adenoma (hyperplastic glandular endometritis 
 of some authors). 
 
 3. Retained bits of placenta or membranes. 
 
 4. Sloughing polypus. 
 
 5. Sarcoma of the body. 
 
 Treatment. — If the disease be diagnosed early, hefore 
 spread and fixation of the uterus to neighbouring structures 
 have taken place, total extirpation of the uterus through the 
 
 vagina should be undertaken. 
 If the size of the vagina will 
 not allow this to b^ carried 
 out, abdominal hysterectomy 
 should be performed. In 
 either case the appendages 
 should be removed, lest they 
 be affected. 
 
 When the disease is too 
 far advanced for extirpation, 
 palliative measures only can 
 be adopted. These are much 
 the same as in the case of 
 irremovable cancer of the cervix, e.g. antiseptic douches, 
 packing of the vagina, curetting of the interior of the uterus, 
 and application of styptics and antiseptics from time to time. 
 
 ifiki^^v- '' 
 
 Fig. 194. — Section through a frag- 
 ment curetted from the uterus, 
 after an incomplete abortion. 
 Decidual cells, glands, and effused 
 blood corpuscles are shown. 
 
 After Results of Vaginal Hysterectomy for 
 Carcinoma Uteri. 
 
 Among the most valuable of recent papers on this 
 subject special reference may be made to that of Leopold, 
 who furnishes statistics regarding 1 94 cases. Of these, ten 
 died soon after operation ; eleven died of other diseases ; 
 fifty died of recurrence of the disease (at the time of the 
 publication of the statistics), or 37.5 per cent. 
 
 f \ 
 
 ■/■'. 
 
RESULTS OF VAGINAL HYSTERECTOMY. 
 
 525 
 
 The time, after operation of the fifty cases, at which 
 death occurred, was as follows : — 
 
 In 3 at 3, 4 and 5 months respectively. 
 
 > 
 
 J ill U 1 
 
 iiuiiLii:^. 
 
 » 
 
 2 „ 7 
 
 
 » 
 
 2 „ 8 
 
 
 > 
 
 4 ., 9 
 
 ' ' A 
 
 > 
 
 3 M 10 
 
 
 > 
 
 21 from 12 to 24 months. 
 
 1 
 
 4 during 
 
 the third year. 
 
 1 
 
 5 
 
 ,, fourth ,, 
 
 1 
 
 I 
 
 ,, fifth 
 
 > 
 
 2 
 
 „ sixth ,, 
 
 The average duration of life was, therefore, in these cases 
 19.7 months. 
 
 Of the ninety patients living, seventy-four had remained free 
 of recurrence. Of the whole 140 cases, therefore, which 
 survived operation and did not die of other diseases, the 
 following table gives their history : — 
 
 Died of recurrent disease, 50 = 35.7 per cent.) Recurrence in 
 Living with recurrence, 16=11.4 ,, ,, j 47. 1 per cent. 
 Living and healthy, 74 = 52.9 ,, ,, 
 
 140=100 „ „ 
 
 Excluding all cases operated on within two years, 123 may 
 be considered. Of these, nine died from operation, nine from 
 other diseases, and one could not be traced. Of the remain- 
 ing 104, 
 
 46 died of a recurrence =44. 2 per cent. 
 58 lived . . . =55.8 „ „ 
 
 The length of time of the patients after operation is as 
 follows : — 
 Of 104 operated on, there lived longer than 2 years 58 = 55.7 per cent. 
 
 „ 84 
 
 
 3 
 
 .. 45 = 53-5 
 
 M 61 
 
 
 , 4 
 
 , 38 = 62.3 „ 
 
 „ 47 
 
 
 5 
 
 , 29 = 61.7 ,, 
 
 » 33 
 
 
 6 
 
 , 22 = 66.6 ,, 
 
 „ 21 
 
 
 7 = 
 
 , 16 = 76.1 ,, 
 
 „ 8 
 
 
 8 , 
 
 , 6 = 75.0 
 
v. 
 
 526 
 
 CARCINOMA UTERI. 
 
 Of these 104, there was recurrence in seven, and the 
 length of time between operation and return was as follows : 
 
 In I over 8 years. 
 ,, I about 7 „ 
 » I .. 6.5 ,, 
 
 In I about 5.9 years. 
 >) I >» 4 4 
 
 I 
 
 4.2 
 
 
 In I al)out 2.6 years. 
 
 Leopold also gives statistics regarding the cases in which 
 operation was carried out when the uterus was freely mov- 
 able, and when it was not. In the former there was a return 
 in 23.7 per cent.; in the latter in 66.1 per cent. 
 
 Leopold believes that in some cases the patient may 
 become infected by cancerous tissue coming into contact 
 with the wound, and he urges that this should be avoided. 
 
 '' \ 
 
 Sarcoma Uteri. ^ 
 
 I. Of the Corpus Uteri. 
 
 Pathology. — Sarcoma occurs in two forms — 
 
 1. Diffuse. 
 
 2. Circumscribed. 
 
 The diffuse form is found mostly in young women. It is 
 composed of round or oval cells, and forms villous or 
 irregular swellings of the mucosa, soft and brain-like in 
 consistence. Polypoidal masses may sometimes extend 
 into the vagina. It may ulcerate and break down very 
 quickly. After removal it tends to return very quickly. 
 
 The circumscribed form may arise in the mucosa or in 
 the connective tissue of the muscular part of the wall. In 
 the former case it may be composed of round, oval, and 
 spindle cells, and may cause a marked swelling of the 
 mucosa which may become polypoidal. In the latter case 
 it exists as localised firm nodules, composed of round, oval, 
 or spindle-shaped cells ; often the fibro-sarcomatous type 
 is found. It is stated by some that probably all these 
 circumscribed sarcomata arise in fibroids ; whether this be 
 
 IS 
 
SARCOMA OF THE CORPUS UTERI. 
 
 s«y 
 
 true or not, it is certain that submucous, interstitial, and 
 subperitoneal tumours may become sarcomatous. 
 
 Ordinary sarcoma may be somewhat transformed into 
 myxosarcoma, and other forms. Sarcoma is believed by 
 some to be found rather frequently along with carcinoma 
 or adenoma. 
 
 The disease may extend along the P'allopian tubes or 
 through to the peritoneum. Secondary nodules may develop 
 in the vagina, lungs, liver, vertebrse, peritoneum, etc. It 
 may cause inversion of the uterus. 
 
 Age at which sarcoma titeri develops. — The following 
 
 FtG. 195. — Large round-cell sar- 
 coma of body of uterus. 
 
 Fig. 196. — Spindle -cell sar- 
 coma of body of uterus. 
 
 interesting table has been prepared by Gusserow. In a 
 series of cases collected by him it occurred — 
 
 Before 20 in 4 cases. 
 From 20-30 ,, 5 ,, 
 
 n 30-39 .. 15 n 
 
 From 40-48 in 28 cases. 
 
 „ 50-60 „ 18 „ 
 Above 60 ,, 3 ,, 
 
 Sjonptoms. — Menorrhagia and metrorrhagia, watery or 
 leucorrhoeal discharge, and sometimes pain, are the 
 earliest symptoms. 
 
 After ulceration occurs, the bleeding becomes more 
 continuous ; the discharge contains considerable debris, 
 and is foetid. The pain may be in some cases very intense ; 
 
 a 
 
V 
 
 528 
 
 CARCINOMA UTERI. 
 
 / 
 
 probably in the cases where fibrosarcoma is developing in 
 the substance of the wall. In other cases there is no pain, 
 or it is only very slight ; probably in those in which the soft 
 sarcoma grows from the mucosa. The patient gradually 
 loses strength and develops a cachectic look. 
 
 Physical signs. — On bimanual examination the uterus is 
 found to be enlarged. Soft, pliable, polypoidal masses may 
 sometimes be felt projecting through the cervix. If the 
 cervix be dilated sufficiently to admit the finger, the 
 irregularities in the cavity may be distinguished. Bleeding 
 is usually easily caused. Fixation of tVe uterus may be 
 
 Fig. 197. — Sarcoma of body of uterus, containing small round 
 and oat-like cells. 
 
 made out, or extension along the tubes, in the broad 
 ligaments, or elsewhere. 
 
 The sound is to be used very cautiously. Scrapings 
 should be made and carefully examined. 
 Differential diagnosis : — 
 
 From hsemorrhagic endometritis. 
 From fibroids ; sloughing fibroids. 
 From carcinoma corporis. 
 Simple adenoma. 
 
 Retained bits of placenta or membranes. 
 
 Prognosis. — The prognosis is most grave in the rapidly 
 
 growing forms. In the slow-growing fibrosarcoma, the 
 
 disease may continue for years, the average period being, 
 
 according to some, three years. It may last, however, for 
 
 I. 
 
 2. 
 
 3- 
 4- 
 
 5- 
 
ff 
 
 TUBERCULOSIS OF THE UTERUS. 
 
 539 
 
 six or eight years. Recurrence after curetting varies greatly 
 in different cases. 
 
 Treatment. — Total extirpation of the uterus is the only 
 means of radical cure. If this be impossible, palliative 
 measures similar to those used in cancer of the uterus must 
 be employed. 
 
 II. Of the Cervix Uteri. 
 
 Sarcoma of the cervix is very rare. It may grow as a 
 mass in the substance of the wall, or may project as a 
 polypus into the vagina. A papillary form is sometimes 
 met with, and sometimes this polypoidal form looks like a 
 hydatid mole, owing to the 
 occurrence of cedema in 
 different parts of it. Myxo- 
 sarcoma or myxo-adeno-sar- 
 coma may be found, and 
 myxochondroma may some- 
 times occur. 
 
 Tuberculosis of the 
 Uterus. 
 
 Tuberculosis in the ^'°: ^98. - Tubercular enclome- 
 
 tritis. Two giant cells are shown. 
 
 uterus IS generally second- 
 ary to the affection in other parts of the body, e.g. phthisis. 
 Very rarely is it primary. In most cases only the corpus uteri 
 is involved. The disease begins in the endometrium, most 
 commonly at the fundus, and afterwards extends. We may 
 find it in the miliary stage, with or without ulceration, in 
 the caseous form, and in the chronic fibroid condition. 
 Owing to obstruction in the cervix the uterus may distend, 
 forming a pyo ^a. 
 
 Tuberculosis, Ji the cervix is rare. 
 
 Kiwisch believes that the puerperium is a predisposing 
 cause for uterine tuberculosis. 
 34 
 
 -4 
 
 
V, 
 
 530 
 
 CARCINOMA UTERI. 
 
 I 
 
 
 Deciduoma Malignum. " 
 
 In 1888 Sanger of Leipzig introduced this term to apply 
 to two cases in which, after abortion, soft, spongy tumours 
 developed in the uterus, with metastases in the lungs, ribs, 
 and otLer parts, and which were believed by him to belong 
 to the sarcoma group. Since that time a considerable num- 
 ber of cases have been described. Owing to the varying 
 nature of the accounts, there is the greatest confusion as to 
 the nature and origin of the growth. At the present time 
 the views which exist may be stated as follows : — 
 
 Relationship to pregnancy. — These cases have been 
 described as occurring within a few days, weeks, or months 
 after full-time labour, abortion, hydatid mole, ectopic 
 gestation. A large proportion have been described in 
 relation to hydatid mole. It is possible that in some cases 
 the primary growth may begin to grow before the pregnancy 
 is ended. The condition has been found at all periods of 
 the sexual life, the largest proportion occurr g between the 
 ages of 20 and 30. 
 
 Clinical features. — Haemorrhage from the uterus is usually 
 the first and most marked symptom ; it occurs irregularly. 
 The uterus is enlarged by the soft growth of the mucosa, 
 which may affect the thickness of the whole wall. After 
 curetting of the mass, rapid return is usual. The rapid 
 development of metastases is a prominent feature. They 
 are most frequent in the lungs, common in the vagina, and 
 may occur in other parts, e.g. nbs, iliac fossa. The disease 
 progresses rapidly, and death usually takes place within six 
 months of the appearance of symptoms. 
 
 Pathology. — There is the greatest discordance of opinion 
 as to the pathology of this condition. By some the growth 
 has been described as carcinoma, by others as sarcoma, and 
 by others as a mixture of carcinoma and sarcoma. 
 
 As to the starting-point, some cases are described as 
 maternal in origin, either from epithelial connective tissue, 
 
DECIDUOMA MALIGNUM. 
 
 531 
 
 or muscular elements ; others are described as foetal, either 
 from the epithelium or connective tissue of the chorionic 
 villi, or from both ; and others are described as a mixture 
 of foetal and maternal elements. 
 
 From a careful examination of the literature, it appears 
 that the following groups may be arranged : — 
 
 1. Those in which the primary growth and metastases are 
 composed of cells of sarcomatous, carcinomatous, or mixed 
 sarcomatous and carcinomatous types. 
 
 2. Those in which the structure is that found in Group i, 
 along with syncytium — irregularly- 
 shaped masses of nucleated plas- 
 modial structure. 
 
 3. Those in which the structure 
 is that found in Group 2, along 
 with structures resembling placental 
 villi. 
 
 In regard to Group i, nothing 
 much need be said, save to point 
 out that the difficulty of deciding 
 sometimes as to the carcinomatous 
 or sarcinomatous nature of some 
 malignant uterine growths is a much older one than the dis- 
 covery of deciduoma malignum, and has been pointed out in 
 connection with the uterus, apart from the influence of preg- 
 nancy, as wtII as in connection with it. Virchow, Hegar, 
 Gusserow, Klebs, and others have referred to this point. 
 The latter author was so impressed with the tendency of 
 these growths to occur together in the corpus uteri, and 
 found the histological differentiation of them so difficult, that 
 he proposed to call them by the term carcinosarcoma. The 
 difficulty of establishing their histological nature will be 
 increased by the complication of the influence of pregnancy. 
 
 Should the growth occur soon after delivery, the remains 
 of decidual cells and of glandular elements may present 
 appearances exceedingly hard to interpret correctly ; more- 
 
 Fig. 199. — Sarcoma of cor- 
 pus uteri. The cells in 
 this section are arranged 
 in a group somewhat re- 
 sembling a cancer group. 
 
 I I 
 
A 
 
 532 
 
 CARCINOMA UTERT. 
 
 over, it is to be remembered that normally the range of 
 variation in the structure of the mucosa in pregnancy and 
 after delivery is considerable (^ide my articles on "The 
 Changes in the Uterine Mucosa during Pregnancy, and 
 in the attached Foetal Structures," Am. Jonrn. Obst.^ New 
 York, 1897). 
 
 The chief feature of these tumours is the large type of the 
 cells which compose them. Now, it is to be noted that every- 
 where else in the body rapidly growing sarcoma is of the 
 small-cell variety. When sarcomata develop in the uterus 
 of a woman who has not been pregnant, or in whom preg- 
 nancy has not taken place for a long time, there is no tend- 
 ency to the formation of large cells. It is evident, then, 
 that this is a characteristic related to pregnancy, and the 
 explanation is probably as follows : — The genetic influence 
 which is due to fertilisation, and which in the beginning of 
 pregnancy leads to the formation of a decidua, is probably 
 not lost for a considerable while after pregnancy, and may 
 be so excited by the irritation of a new growth that the con- 
 nective tissue elements multiply and take on that develop- 
 ment to which they are physiologically peculiarly disposed, 
 namely, the formation of cells of large size. This will 
 probably be all the more noticeable when the new growth 
 is one developing in connection with the connective tissue 
 elements. 
 
 The occurrence of large connective tissue cells in the 
 uterine mucosa has not been noted where the influence 
 of a past pregnancy does not come into play. Thus in 
 Overlach's phosphorus poisoning case, and in Ruge's 
 endometritis case, where large cells were found, the in- 
 fluence of a past abortion could not be excluded. Such 
 cases prove that the genetic influence may extend for many 
 weeks after labour ; and we already know that it may act at 
 a distance, because decidual formation may take place in the 
 uterus when fertilisation occurs in one tube, or it may occur 
 in the opposite tube {^vide my book " Ectopic Pregnancy "). 
 
// 
 
 DEC I DUO MA MA LIGNUM. 
 
 533 
 
 It is not, therefore, remarkable that sarcomatous changes 
 in a uterine mucosa, which has recently been submitted to 
 the influence of pregnancy, may be marked by the formation 
 of cells of a large or decidual type ; and it seems to me 
 unnecessary to apply the term "deciduoma ma]ignum"to 
 this group. As regards the rapidity of growth, it has long 
 been known that this is a special characteristic of malignant 
 growths of the uterus developing in the puerperium — very 
 possibly related to the weakened condition of the woman in 
 association with the profound 
 changes which have occurred fffj/ 
 
 in the body metabolism. 'HJ^^W^* 
 
 Group 2. — In this group, of 
 which the case published by ^^ 
 Whitridge Williams in 1895 
 
 >\ 
 
 w. 
 
 h *• 
 
 Whitridge Williams in 1895 V^^WF^}^^ 
 
 may be taken as a type, besides /^MfJ^o!^ ©^ 
 
 the large, malignant, decidua- ^^^>%'WJ!'^it 
 
 like cells which compose the ij^^^^/y 
 
 U 
 
 Fig. 200. — Deciduoma malig- 
 nurn. Syncytial masses and 
 sarcoma-like cells are shown. — 
 Drawn from a specimen kindly 
 given me by Professor Spencer, 
 University College, London. 
 
 like cells which compose the 
 great part of the tumour, there 
 are masses of syncytium, vary- 
 ing in size and shape, often 
 found in bands, composed of 
 granular, nucleated protoplasm 
 — plasmodial in appearance, 
 and vacuolated in different parts. Sometimes the masses 
 may be found burrowing through the walls of venous 
 sinuses. 
 
 This structure is also found in the metastatic growths, 
 where it may be more abundant and in more varied shapes 
 than in the primary growth. Some of the masses exactly 
 resemble sections of the early epiblastic buds found growing 
 from the chorion in pregnancy. 
 
 In the midst of the cells of the tumour blood is found, 
 though often no distinct vessels can be made out. 
 
 Regarding these growths there is very great dispute, 
 especially with regard to the syncytium. Some regard them 
 
 1 
 
 m 
 
 1 
 
I 
 
 V. 
 
 I 
 
 I ! I 
 
 534 
 
 CARCINOMA UTERI. 
 
 as sarcomata or carcinosarcomata of maternal origin. 
 Kanthack and others regard them mainly as sarcomatous 
 developments of the connective tissue of the mucosa, the 
 syncytial masses being due to degeneration in the sarco- 
 matous cells. Those who oi)i)ose this view state that the 
 syncytium is too abundant and too distinct a formation to 
 be accounted for in this way, and that no such marked ap- 
 pearances are ever seen in sarcoma occurring elsewhere in 
 the body. 
 
 Others believe that these tumours are entirely of ff£tal 
 origin, the decidua-like cells being derived either by sar- 
 comatous changes in the mesoblastic portion of the villi 
 or by proliferation of the deep layer (Langhans') of the 
 epiblastic covering of the villi, the syncytium being derived 
 from the superficial layer of the epiblast, which is a syncytial 
 structure. Another view is to the effect that the tumours 
 are made up of a mixture derived both from foetal and 
 maternal sources. 
 
 The important feature of the tumours of this group are 
 the syncytial masses. All observers are agreed upon their 
 great resemblance to the syncytium normally found in the 
 uterus in pregnancy. If it can be established that their 
 formation is not due to degenerative processes in the 
 sarcoma, but Ihat they are identical with the syncytium of 
 pregnancy, then it will be necessary to regard the growth as 
 of undoubted foetal origin — an epiblastoma^ if I may use the 
 word. For there can now be no doubt that the syncytium 
 of [)regnancy is derived entirely from the outer portion of 
 the epiblastic covering of the ovum. That it is not of 
 maternal origin the researches of Kastchenko, myself, and 
 others clearly show. It is found at first on the early ovur^, 
 from which it spreads to the surface of the decidua, which is 
 related to the chorion ; it has trophoblastic powers and can 
 penetrate the decidua, reaching even into the muscular part 
 of the wall ; it opens the maternal sinuses in the serotina, 
 and portions of it may be found free in the veins, and may 
 
DEC I DUO MA MAUGNUM, 
 
 ■' t 
 535 
 
 thus be carried as small emboli some distance from the 
 uterus, even to the lungs. 
 
 It would not, therefore, appear to me marvellous if the 
 ffjetal epiblast should sometimes overstep the normal range 
 of its activity, and take on malignant action. A dermoid 
 cyst of the ovary is a tumour derived from the early epiblast, 
 and it is widely recognised thai, in case of rupture, it is very 
 apt to set up secondary growths in the peritoneum as a 
 result of infection by its epiblastic elements. 
 These may become malignant. 
 
 Group 3. — This is made up of cases in 
 which the tumour has developed after a hy- 
 datid mole has been expelled from the uterus. 
 The new growth and metastases are in some 
 cases composed entirely of masses of syncy- 
 tium and of structures exactly resembling, on 
 section, villi in various stages of development, 
 i.e. solid syncytial buds, vacuolated buds or 
 rings of epiblast filled with mucoid tissue ; 
 in other cases besides these elements there 
 are large cells, which may possibly have 
 originated from the Langhans or deep layer 
 of the epiblast. 
 
 The appearances presented by the first of 
 these classes are so very like those seen in 
 microscopic sections of the placenta, both 
 in uterine and ectopic gestation, that one is 
 inclined to agree with Klebs in regarding the new growth as 
 a case of foetal parasitism, due to malignant changes in foetal 
 remains left in the uterus. 
 
 Treatment. — Owing to the rapid formation of meta- 
 stases, operative measures will often be useless. When, 
 however, the growth is localised to the uterus or tube, 
 secondary growths not having occurred, complete removal 
 of the whole organ is the only treatment to be em- 
 ployed. When removal is impossible, it may be neces- 
 
 FiG. 201. — Decid- 
 uoma malig- 
 num villus-like 
 Mass in a tum- 
 our of the 
 uterus, which 
 developed after 
 the expulsion of 
 a hydatid mole. 
 — Drawn from 
 a specimen 
 kindly given to 
 me by Professor 
 Spencek, Uni- 
 versity College, 
 London. 
 
 if 
 
 liil 
 
 
 \m 
 
536 
 
 CARCINOMA UTERL 
 
 sary to curette the cavity of the uterus as a palliative 
 measure. 
 
 Cystic Distensions of the Uterine Cavity. 
 
 Hydrometra, hDematometra, and pyometra may follow 
 congenital or acquired atresia of the cervix {vide p. 436). 
 After the menopause they are sometimes met with. They 
 required to be emptied by opening the cervix. 
 
 Uterine Polypi. 
 
 Different varieties of these are found, e.g. — 
 
 1. Pedunculated Nabothian follicle {vide p. 419). 
 
 2. Submucous fibroid {vide p. 475). \ 
 
 3. Mucous polypus. 
 
 4. Fibrous polypus of the mucosa of the corpus uteri. 
 
 5. Placental and fibrinous polypi. 
 
 6. Papilloma of the cervix. 
 
 7. Sarcoma. 
 
 8. Carcinoma. 
 
 Mucous polypi. — These grow most frequently from the 
 cervix. According to some authorities they occur only as 
 a result of inflammatory changes, being a mere local hyper- 
 trophy and hyperplasia. While many undoubtedly originate 
 in this way, I think that some must be regarded as simple 
 adenomata. These polypi vary from a pea to a hen's egg 
 in size. They are made up of the elements of the mucosa 
 and are very vascular, usually of a cherry-red colour. Often 
 more than one are found. 
 
 They are covered with columnar epithelium ; when growing 
 near the os externum, they may be partly or, sometimes, 
 entirely covered with stratified squamous epithelium. They 
 are made up of spaces lined with columnar or cubical 
 epithelium, lying in a delicate connective tissue stroma, rich 
 in capillaries ; often blood is found diffused among the fibrils. 
 
UTERINE POLY FT. 
 
 537 
 
 metrorrhagia v^ccur. 
 
 In some cases, where the spaces are somewhat distended, 
 the lining epithelium may be considerably flattened. They 
 contain thick or thin mucus. 
 
 As these polypi grow and descend they dilate the cervix. 
 Sometimes those growing in the body do not tend to work 
 their way down through the cervix. 
 
 They sometimes tend to recur ; in some cases there is a 
 malignant tendency. 
 
 Sometimes these growths may have a covering of stratified 
 squamous epithelium, though growing from the cervical 
 mucosa. 
 
 Diagnosis. — Menorrhagia and 
 Haemorrhage is apt to occur after 
 violent exertion, straining at stool, 
 coitus, physical examination, in 
 cases in which the polypus hangs 
 in the vagina. Leucorrhoea is 
 common. The muco-purulent dis- 
 charge maybe from the tumour as 
 well as from the uterine mucosa. 
 Pain is rare save when the tumour 
 is big, and has not passed through 
 the cervix; it is chiefly present 
 at menstruation. 
 
 Sometimes anaemia is rapidly brought about ; the patient 
 may have a cachectic appearance in some cases, which may 
 increase the suspicion of malignancy. 
 
 Sterility may be present, and may be due sometimes to 
 plugging of the cervix ; sometimes, to associated inflamma- 
 tion in the mucosa. 
 
 Sometimes with these as with other polypi, pigmentation 
 and enlargement of the breasts, morning sickness, etc., may 
 be present. When the polypus projects beyond the cervix 
 it is felt as a soft, velvety mass. If it does not project much 
 it may be mistaken for a catarrhal patch, sometimes for 
 malignant disease, especially if ulceration or gangrene be 
 
 Fig. 202. — Section through 
 part of a mucous polypus. 
 
 * 6 i 
 
 t\ 
 
 f\ 
 
 1 
 
 % 
 
 1 
 
 j:i 
 
 1 
 
 
 1 
 
 11 
 
 1 
 

 V. 
 
 538 
 
 CARCINOMA UTERI. 
 
 present. Through the speculum the mass is seen to be 
 of a cherry-red colour. 
 
 When the growth is within the uterus, it may easily be 
 missed, for the symptoms may be" considered as being due 
 to other conditions. Very often patients are allowed to 
 run for a long time with the condition undiagnosed. In 
 doubtful cases, the cervix may be dilated, and the cavity 
 carefully explored with sound, finger, or curette. With 
 small polypi the uterus is not necessarily much enlarged. 
 
 If microscopical examination of fragments be made, it 
 may be impossible to distinguish a glandular endometritis 
 from a piece of a simple adenoma. 
 
 Differential diagnosis : — 
 
 1. From the various other forms of polypi above- 
 mentioned. 
 
 2. From hcemorrhagic endometritis. ^ 
 
 3. From malignant disease of the body or cervix. 
 
 4. From remains of membranes, placenta, or decidua. 
 
 5. From early pregnancy. 
 
 Fibrous polypus of the mucosa of the corpus uteri. — 
 Haultain has described an interesting case in which, in an 
 old woman of 70, a series of large polypi developed 
 from the mucosa of the body, leading to hgemorrhages. It 
 was made up of fibrous tissue in the centre, and of more 
 cellular tissue near the periphery ; it was covered with 
 columnar epithelium, and contained canals, evidently gland- 
 like spaces. This polypus verges towards sarcoma. 
 
 Placental and fibrinous polypi. — Remains of membranes 
 or placenta may give rise to a coagulation of blood, which 
 may undergo partial organisation, forming a large mass which 
 may hang from the wall of the uterus like a polypus. It tends 
 to undergo decomposition, giving rise to a foetid discharge. 
 
 Diagnosis. — There are irregular losses of blood, which 
 may be very profuse. Other symptoms are due to the sub- 
 involution. When decomposition occurs, the condition 
 may be mistaken for malignancy. 
 
 !\ 
 
 
UTERINE POL YPL 
 
 539 
 
 P'ibrinous polypi may sometimes be developed independent 
 of the puerperal state. They may sometimes develop on the 
 site of removal of a large intra-uterine polypoidal tumour, 
 the blood becoming deposited, layer u[)on layer. 
 
 Papilloma of the cervix. — This is very rare as a simple 
 tumour. It may spring from the mucosa of the cervix, and 
 extend downwards as a cauliflower mass, being covered with 
 cubical or columnar epithelium. It is said to grow more 
 slowly in the vagina of a nullipara. It may arise near the 
 OS externum, and be covered partly with stratified squamous, 
 
 Fig. 203. — Section through part of a placental and fibrinous 
 polypus. Degenerating villi surrounded by fibrin are 
 shown. 
 
 partly with columnar epithelium. It may be sometimes 
 entirely covered with stratified squamous epithelium. These 
 contain varying proportions of connective tissue and gland 
 spaces. Malignant cauliflower growths are more common 
 in the cervix. 
 
 Diagnosis. — Leucorrhoea is the most constant feature. 
 Sometimes it may be bad smelling, from necrosis or ulceration 
 of a portion of the tumour, and may lead to a diagnosis of 
 malignancy. Haemorrhages may occur. On examination, 
 the cauliflower-like mass is felt. It may, in some cases, 
 bleed on examination. 
 
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 ''3 WEST MAIN STREET 
 
 WEBSTER, NY. 14580 
 
 (716) 872-4503 
 

 ^4^^ 4 
 
 9 
 
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 m 
 
J40 
 
 CARCINOMA UTERI. 
 
 Sarcomatous polypi may develop from the uterine mucosa, 
 or may grow from the cervix into the vagina {vide p. 529). 
 Carcinomatous cauliflower growths may also project into the 
 vagina from the cervix. 
 
 Treatment. — Polypi are to be completely removed- 
 mucous polypi, by twisting of their necks with forceps ; 
 cervical growths hanging in the vagina, by ligature of the 
 base, the tumour being cut away beyond it. r- 
 
 Placental and fibrinous polypi are removed best with a 
 large spoon curette. Intra-uterine polypi are best removed 
 according to the plans described on p. 494. In all 
 cases it is well to curette the uterus when the tumour is 
 removed. In many cases it is necessary to dilate the cervix 
 considerably before the polypus can be taken away. In 
 the case of a malignant polypus, high amputation of the 
 cervix or total extirpation of the uterus may be carried out. 
 
 '"•I- 
 
 * 1 
 
 \ I 
 
 i\ 
 
r 
 
 CHAPTER XVIII. 
 
 AFFECTIONS OF THE VULVA. 
 
 Malformations. 
 
 . < ■ 
 
 Double vulva. — This is a rare condition. There may be, 
 as in the case of Katherine Kaufmann, reported by 
 Suppinger, a double vulva, each with clitoris, hymen, 
 urethra, and anus. Here there was also a bladder and a 
 unicornuate uterus, with an ovary and tube in each half 
 of the pelvis. 
 
 Infantile vulva. — In the adult this condition may be found. 
 It may be associated with defective development of the 
 internal genitals \ also with diseased states, e.g. chlorosis. 
 
 Malfonnations of clitoris and labia. — The clitoris may be 
 absent. It may be bifid ; this may be found in epispadias, 
 in which condition, also, there may be complete absence. 
 The organ may be small or abnormally large. 
 
 The labia majora may be wanting ; this condition is 
 usually found with extroversion of the bladder. They may 
 be adherent. The nymphae may also be glued together. 
 They may be absent in epispadias. There may be some- 
 times two or thret on one side. Sometimes they may be 
 hypertrophied, e.g. as in the case of the " Hottentot apron." 
 
 Atresia or defectus vulva. — Rarely, a foetus is found in 
 which the genital furrow has not formed, nor any division 
 of the genital tubercle. The rectum, genital canal, and 
 bladder may be in communication, or the rectum may end 
 blindly, and be separate from the bladder. Sometimes 
 
 f 
 
V, 
 
 542 
 
 AFFECTIONS OF THE VULVA. 
 
 there is an anus. There is usually no vagina and no 
 urethra. In such cases the bladder and genital canal are 
 usually greatly distended with urine. 
 
 Fig. 204. — Com- 
 plete atresia 
 of the vulva. 
 Rectum, va- 
 gina, and 
 bladder com- 
 municate. 
 
 SCHROEDER. 
 
 \ I 
 
 Fig. 205.— Com- 
 plete atresia 
 of the vulva. 
 The rectum is 
 separate from 
 the allantois. 
 The bladder 
 and vagina are 
 distended with 
 urine. 
 
 SCHROEDER. 
 
 W 
 
 Fig. 206. — Per- 
 sistence of the 
 cloacal condi- 
 tion, owing to 
 the non -de- 
 velopment of 
 the perineal 
 septum. 
 
 SCHROEDER. 
 
 Fig. 207.— Hy- 
 pospadias. 
 The condition 
 of persistent 
 urogenital 
 sinus is shown. 
 
 SCHROEDER. 
 
 Fig. 208.— Hy- 
 pospadias. 
 The urethra is 
 absent, the 
 bladder and 
 vagina open- 
 ing directly 
 into the vesti- 
 bule. 
 SCHROEDER. 
 
 The condition is mainly found in non-viable foetuses, e.g. 
 acephalic and sympodial types. 
 
 In some cases the atresia is only superficial, being due to 
 the blending of the labia majora or minora ; usually it is 
 incomplete, a small opening being found near the clitoris 
 
HERMAPHRODITISM. 
 
 543 
 
 
 through which menstrual blood can escape. The condition 
 is probably due to an adhesive vulvitis. 
 
 Persistence of a cloaca. — Sometimes the perineal septum 
 is not developed, the urogenital sinus remaining open and 
 communicating with the rectum. 
 
 Hsrpospadias. — This is found in two forms. In one, 
 the perineum has fully developed, but the urogenital sinus 
 has retained its embryonic condition (persistent urogenital 
 sinus). 
 
 The vestibular canal is long, the urethra and vagina 
 opening into it high up. 
 
 In the other form the urogenital sinus has disappeared ; 
 there is no arethra, the bladder and vagina opening into 
 the vestibular canal. Here the lower part of the allantois, 
 instead of forming a urethra has simply given origin to 
 the bladder. On examining the case, the opening of the 
 bladder is seen on the anterior vaginal wall. 
 
 Hermaphroditism. — True. — For a long time it has been 
 believed that both ovaries and testes may be found in the 
 same person, on one or both sides, the external organs of 
 one sex predominating, thus determining the sex. Recently, 
 strong criticism has been advanced in regard to these long 
 held views, so that the occurrence of true hermaphroditism 
 may be considered as very doubtful. (I have already given 
 Nagel's reason against its non-existence, see p. 8.) 
 
 Pseudo-hermaphroditism. — Here there are malformations 
 in the external genitals, whereby a resemblance to the 
 opposite sex is produced. 
 
 {a) In the female, the clitoris may be hypertrophied, re- 
 sembling the penis. The labia may be fused, and possibly 
 also the nymphae, hiding the vulvar opening, and forming a 
 condition which resembles the scrotum. 
 
 Sometimes there may be a hernia of the ovary into the 
 labium, increasing the resemblance. 
 
 At birth, if this condition be recognised, the labia may 
 be separated, usually revealing the true nature of the case. 
 
 
 \'t 
 
 
V 
 
 544 
 
 AFFECTIONS OF THE VULVA. 
 
 J 
 
 The clitoris may be i or 2 in. in length. In these cases 
 the internal genitals are female, though they may be irregu- 
 larly developed. ' \ ; 
 
 (6) In certain males, often monorchid or cryptorchid, there 
 are external female characteristics, e.g. large breasts. There 
 may be a depression in the middle line of the scrotum, and, 
 if the testes are absent, there may be considerable resem- 
 blance to the external genitals of the female. 
 
 Most cases, however, are instances in which there is 
 hypospadias in the male, i.e. the persistence of urogenital 
 sinus, or perineoscrotal fissure. The penis may be small, 
 the urethra opening at its base. A frenum extends from 
 under the end of the pen^ to the urethra. Below the 
 latter is a small vulvar orifice. A hymen may sometimes 
 be found, and there may be rudimentary nymphse. The 
 vagina varies in extent. The uterus and tubes may also 
 be developed. Sometimes the vagina may open into the 
 prostatic part of the urethra. The testes are rudimentary, 
 and secrete sterile semen. The breasts, larynx, buttocks, 
 and thighs may be feminine. The beard is scanty or well 
 developed. 
 
 These persons are generally considered as females, and 
 they may marry men. Their husbands usually have coitus 
 by the dilated urethra. Sometimes irregular bleedings from 
 the urethra are regarded as menstruation. But in some 
 cases where the uterus is present there is undoubted mens- 
 truation, though the ovaries be absent. ' 
 
 In many cases these persons prefer the female, and are 
 able to go through coitus to a certain extent. They are 
 usually ill-balanced in mental organisation. ' 
 
 There is another condition in the male, namely, epispadias, 
 in which the urethra and bladder are open anteriorly, which 
 might possibly be mistaken for pseudo - hermaphroditism, 
 but the nature of the case is evident from the presence of 
 scrotum, testicles, and normal perineum. 
 
 W 
 

 are 
 I are 
 
 Us, 
 
 ich 
 
 Im, 
 
 of 
 
 VUL VITIS, 
 
 Inflammation in the Vulva 
 
 54$ 
 
 (Vulvitis). 
 
 Pathology. — Vulvitis may be acute, subacute, or chronic. 
 It may start on the outer surface or on the parts in apposi- 
 tion, and may begin in the haii follicles, the sweat glands, 
 the sebaceous glands, Skene's glands, the ducts from the 
 Bartholinian glands, the meatus urinarius. 
 
 The surface surrounding the introitus vagina, and urethral 
 orifice, or the labia, may be red, swollen, and tender. The 
 orifice of the Bartholinian duct may be surrounded by a 
 red areola, and pus may be squeezed out. Small acne- 
 like swellings may be produced in some cases, and small 
 localised abscesses may be formed. An abundant discharge 
 may cover the parts. Sometimes a phlegmonous vulvitis 
 is found. Erosions and ulcerations of the surface may be 
 produced. The glands of Bartholin may be affected, and 
 they may become distended with pus. The inguinal glands 
 may be secondarily affected. 
 
 Etiology. — Specific venereal diseases ; it may be secondary 
 to vaginitis ; it may result from irritating discharges r:aused 
 by carcinoma, vesico-vaginal fistula, etc. ; dirty habits in fat 
 women ; masturbation, awkward coitus, ill-fitting pessaries ; 
 dribbling of urine in dirty, weakly, or strumous childrjn, 
 In most of these cases no doubt the chief agent in the 
 inflammation is some form of micro-organism. 
 
 Symptoms. — There is tenderness or pain in the region of 
 the vulva, aggravated on walking, on micturition, and on 
 coitus. There is a free discharge. When very acute, febrile 
 symptoms may be produced, especially if suppuration occur 
 in the inguinal glands. 
 
 Treatment. — In acute cases the patient should be kept 
 quiet for a few days. The parts should be douched several 
 times daily with boric, lead and opium, corrosive sub- 
 limate, or formalin (i in 3000) lotions. The irritated parts 
 35 
 
 /■*!>:" 
 
 i !■ 
 
 I \ 
 
 \ \ 
 
 
546 
 
 AFFECTIONS OF THE VULVA. 
 
 V 
 
 may be painted with silver nitrate (i in 50) to lessen the 
 pain and to act as an antiseptic. 
 
 After douching, the parts may be powdered with a mixture 
 of naphthaline and calamine, or of iodoform and talc (i in 
 10/, and the labia may be kept apart by antiseptic wooi. 
 
 The orifice of the Bartholinian duct should be cauterised 
 with a nitrate of silver pencil, after enlarging it with a fine 
 knife. Crypts should be burned with a fine cautery point. 
 Abscesses should be opened, their lining wall destroyed 
 with a cautery, and the cavity packed with iodoform gauze. 
 In chronic cases, corrosive sublimate or copper sulphate 
 lotions may be used. ■ \\ 
 
 (Edema and Gangrene. 
 
 i 
 
 CEdema is noticed in pregnancy sometimes, or in the 
 puerperium. It may also occur in connection with general 
 anasarca. Sometimes it may accompany chancres, and may 
 be found on the labia minora, labia majora, or prepuce of 
 the clitoris. 
 
 Gangrene may occur in w^eakly infants ; in various septic 
 and acute febrile conditions, e.g. typhoid, scarlet fever, etc. 
 It may follow injury in labour, if sepsis develops. 
 
 Treatment. — Local antiseptic applications are to be 
 made, and adhesions prevented from forming. 
 
 Eczema Vulvae. 
 
 This affection is found chiefly on the labia majora, but it 
 may affect the mons veneris and other parts. 
 
 In the acute condition there is swelling of the skin with 
 
 '\ a small vesicular eruption ; there is itching and tenderness. 
 
 Considerable discharge may be produced. Chronic eczema 
 
 may follow the acute affection, or may be chronic from the 
 
 first. The skin is rough, scaly, and may be fissured and 
 
 \ excoriated ; it may also be considerably hypertrophied. 
 
ESS 
 
 1 
 
 be 
 
 lut It 
 
 r'ith 
 less. 
 ;ma 
 
 the 
 land 
 
 ECZEMA VULVAt. 
 
 547 
 
 Rheumatism is an important factor in predisposing to 
 these attacks ; in some cases they occur only in the 
 spring. The scrofulous diathesis may have an influence 
 also. 
 
 Treatment. — Locally, in the acute stage, alkaline and bran 
 baths are beneficial, followed by a mild ointment. Starch 
 poultices may also be employed. Painting with nitrate of 
 silver gives relief from the heat and itching. The parts 
 should not be scratched. It may be necessary to wear 
 drawers at night to prevent this. Often the following paste 
 cures quickly : — ,, , 
 
 R 
 
 Acidi salicylici 
 
 Resorcini, 
 
 Ichthyolici, 
 
 Lanolini, 
 
 Vaselini, 
 
 Zinci oxidi, 
 
 Pulveris amyli, 
 
 ■) 
 
 ana grs. v. 
 
 tn X. 
 
 ana 3ii. 
 
 Misce leniter terenda diu, fiat pasta. 
 
 In chronic cases, when there is leathery infiltration, com- 
 presses of absorbent wool, soaked in a lotion of water, con- 
 taining one quarter the quantity of the following mixture, 
 are helpful : — ■ , 
 
 Resorcini,) 
 Glycerini, J 
 Sp. vini rect. 
 
 ana 5.0 
 90.0 
 
 This may be succeeded by the above-mentioned paste, 
 or by an ointment containing equal parts of lead plaster 
 and the best vaseline. Sometimes it is well to paint the 
 parts with iodine. ' ■ ' 
 
 General measures must not be forgotten. The diet must be 
 simple. The bowels must be kept regular. The influence 
 of rheumatism or scrofula should be kept in mind. : , 
 
 
548 
 
 AFFECTIONS OF THE VUL VA. 
 
 Herpes Zoster. ^ 
 
 =^ .V 
 
 This condition is sometimes found. The vesicles may 
 be few or many, discrete or confluent. Sometimes large 
 bullae may be formed. In the early stage there is redness 
 round about. They may give rise to superficial ulcers with 
 crenated edges. A crust usually forms over these, under 
 which healing takes place in the course of a week or two. 
 There is generally considerable heat and smarting pain. It 
 may be found with or without local irritating conditions. 
 Sometimes it may occur monthly before menstruation ; 
 sometimes it is found in pregnancy. The inguinal glands 
 are often painful. It must not be mistaken for syphilides 
 or soft chancre. 
 
 Treatment. — Early, the vesicles should be painted with 
 flexible collodion, which should be renewed daily. 
 
 Where large blebs form they should be pricked with an 
 aseptic needle, and the part should be dusted with an anti- 
 septic powder and covered with antiseptic absorbent wool. 
 The ulcers are treated in this way too ; they should also be 
 touched with nitrate of silver solution. Pain may be assuaged 
 by local bran baths. 
 
 Lupus of the Vulva. 
 
 Several varieties are found. There is always some degree 
 of hypertrophy and often ulceration. The ulceration may 
 be very superficial and of a deep red colour. Sometimes 
 a number of nodules can be seen on the ulcer. Healing 
 often takes place on one side, as advance is marked on the 
 other. It may extend irregularly in various directions, or 
 it may eat deeply. Perforation of rectum and bladder 
 may be caused. Interference with the urethra may be 
 brought about by cicatrisation. There is not a very abundant 
 discharge. j.' _ . . , , "s; 
 
 The hypertrophied parts may be very large. The labia 
 
1 
 
 L UPUS — TUBERCUL OS/S. 
 
 549 
 
 or clitoris may be affected, either continuously or in de- 
 tached areas. These swellings are usually not painful. 
 The disease progresses slowly. It may be mistal^n for 
 malignant disease, venereal disease, or for elephantiasis. 
 Tuberculosis is a predisposing cause, and the affection is 
 probably a local tuberculosis. \ 
 
 Whitiidge Williams believes that some of the described 
 cases have been due to carcinoma, syphilis, elephantiasis, or 
 tuberculosis. 
 
 Treatment. — The hypsrtrophied areas should be excised, 
 and the ulcers cauterised. The superficial ulcerations may 
 be scraped. 
 
 Tuberculosis of the Vulva. 
 
 Williams thinks that some of the cases which have been 
 described as lupus are of undoubted tubercular origin. 
 
 True tuberculosis, in which the bacillus has been found, 
 or inoculation results obtained, are very rare. In the cases 
 described, phthisis was also present. Ulcers were formed 
 with irregular edges, and having a base studded with 
 granulatioiio. 
 
 Erysipelas. 
 
 Erysipelas is sometimes primary in newly-born children. 
 It may be found in women, often occurring periodically in 
 association with menstruation, or in amenorrhoea. 
 
 
 y 
 
 Varix. 
 
 A varicose condition of the vulva may be found in con- 
 nection with large tumours in the pelvis or in connection 
 with pregnancy. Masses of considerable size may be formed. 
 There is produced a feeling of weight and discomfort. They 
 may rupture spontaneously, or as a result of traumatism, or 
 they may become inflamed. 
 
55° 
 
 AFFECTIONS OF THE VULVA. 
 
 H;i-:matoma. 
 
 r 
 
 This may occur in non-pregnant women as the result 
 of a blow, or in pregnant women as the result of injury 
 during labour. The sv/elling formed is of a violet colour. 
 It may absorb, rupture, or suppurate. 
 
 Treatment. — If small, it should be leit alone, the patient 
 being icept quiet and cold applications applied ; the vulva 
 and vagina being washed regularly with an antiseptic lotion. 
 If large, it should be opened, the blood clot cleaned out, 
 iodoform gauze stuffed in the cavity, the bleeding vessels 
 being held for a time, if possible, with forceps. 
 
 Kraurosis VuLVi«. 
 
 This term is applied to a condition, probably of inflam- 
 matory origin, which may occur in women at any age, but 
 especially after the menopause, affecting the external genitals. 
 The tissues get dry, brittle, and atrophied, and are easily 
 torn. The sebaceous glands disappear as well as most of the 
 sweat glands ; the corium is atrophied, the papillae are ill- 
 developed, and fissures tend to develop. In parts a small- 
 celled infiltration may be found in the corium. At the 
 edges of the diseased part, according to Orthmann, there is 
 hypertrophy of the tissues and abundant small-cell infiltra- 
 tion. Prolapse of the urethral mucosa or caruncle may be 
 found with this condition. 
 
 Symptoms. — Sometimes there are few or none. Usually 
 there is itching and burning, especially during micturition ; 
 there may be some discharge. Coitus is painful or im- 
 possible. 
 
 Treatment. — The only means of relief is afforded by the 
 removal of the affected part. ^ 
 
 A Pruritus Vulvae. 
 
 This is the condition in which there is a feeling of itchi- 
 
 f\ 
 
PRUK/TUS. 
 
 55« 
 
 
 
 Fig. 209. — Fibrosis of a genital cor- 
 piiscle of Krause in pruriius vulvae. 
 
 ness, more or less constant, in some part of the external 
 genitals. 
 
 Etiology. — This condition may be caused reflexly, e.g. by 
 the presence of worms in the rectum, by various diseases in 
 the pelvis. It may be due to local irritating conditions, e.g. 
 kraurosis vulvae, eruptive 
 and inflammatory affec- 
 tions, the drying of dia- 
 betic urine on the vulvae, 
 discharges from diseased 
 states of vagina and 
 uterus, worms in the 
 vulva and vagina, con- 
 gestion of the parts. 
 Some years ago I showed that in another class of cases 
 pruritus was associated with the development of a slowly 
 progressing fibrosis, affecting both terminal nerves and 
 nerve endings. Sanger has also found the same changes. 
 Several writers state that some cases are purely neurotic 
 in origin. Thi? may be so, but it cannot be definitely 
 
 . established unless parts 
 
 are cut out and sub- 
 mitted to microscopic 
 examination. 
 
 Seat of pruritis. — 
 Most commonly the 
 clitoris and labia minora 
 are affected. The labia 
 majora, mons veneris, 
 perineum, or inner side of the thigh, hymen, or introitus 
 vaginae may also be attacked. 
 
 Symptoms. — In some cases the itching is constant, in 
 others paroxysmal. It is worse at night in bed, and is also 
 made worse by movements. Sometimes the condition is 
 so bad that the woman may become a complete nervous 
 wreck. There are cases on record in which suicide ha^- 
 
 Fig. 210. — Fibrosis affecting pirt of a 
 Meij.sner's corpuscle in the clitoris in 
 pruritus vulvse. 
 
■I ! 
 
 552 
 
 AFFECTIONS OF THE VULVA. 
 
 been committed. Local excoriations, eruptions, and hyper- 
 trophy of the skin may result. On microscopic examination, 
 subacute inflammatory changes may often be found as a 
 result of the scratching. 
 
 Treatment. ^ — Where sonie distinct cause can be made out 
 it should be attended to. Various local applications may 
 give relief, e.g. corrosive sublimate (i in looo), boracic acid, 
 carbolic acid, nitrate of silver, alkaline lotions ; chloroform 
 (2 parts) and oleum amygdalae (60 parts) ; ointments con- 
 taining menthol, cocain, opium, or belladonna. Various 
 drugs have also been used internally, e.g. potassium bromide, 
 sulphonal, arsenic, etc. 
 There are cases which resist all these measures. The 
 
 only method of dealing satis- 
 factorily with these is by com- 
 plete removal of the affected 
 part. 
 
 The operation is a simple 
 one. The skin (it may be, the 
 clitoris and labia minora) is 
 removed, and the raw surface closed with continuous catgut, 
 and dressed antiseptically. 
 
 It is important not to remove parts only affected secon- 
 darily, as a result of irritation due to the itching. The 
 central portion should be taken away, and the surround- 
 ing subacutely inflamed tissues allowed to become normal. 
 Sometimes it is necessary, however, to perform a second 
 operation, removing a small portion affected with the primary 
 trouble which wa? left behind. 
 
 Elephantiasis. 
 
 r 
 
 This disease is mainly found in the tropics. It may 
 affect the labia and clitoris, and may lead to the formation 
 of large masses. There is a hypertrophy and hyperplasia of 
 the skin, generally with great dilatation of the lymph spaces. 
 
 Fig. 211. — Fibrosis of nervein 
 the clitoris in pruritus vulvae. 
 
 IV 
 
NEW GROWTHS. 
 
 553 
 
 The surface may be smooth and shining, or warty. It may 
 be hard or soft on palpation. The affection may begin 
 suddenly or develop slowly. 
 
 Sjanptoms. — There is often itching, smarting, and a feeling 
 of weight or discomibrt. There may be some discharge. 
 Walking, coitus, micturition, and defaecation may be inter- 
 fered «vith. 
 
 Treatment. — The diseased part should be removed. It 
 is best to cut away from behind, closing the wound bit by 
 bit as the incision is made. 
 
 New Growths. 
 
 Carcinoma. — Primary cancer of the vulva is not common. 
 It most often develops at the junction of the labia majora 
 and minora; also in the clitoris and around the urethral 
 orifice. All forms are found, most commonly epithelioma. 
 It usually begins as a hard nodule in the skin. This may 
 protrude and become warty, or ulceration may take place 
 leading to a blood-stained discharge. When it begins on 
 one side, the opposite labium may become infected, ap- 
 parently by contact inoculation. Surrounding tissues 
 gradually become involved. There is no tendency to 
 spread up the vagina, save when the disease affects the 
 urethral wall. The inguinal glands become affected. Me- 
 tastases develop in different parts. 
 
 Symptoms. — Pruritus is the earliest symptom. It may be 
 very marked when the clitoris is affected. There is a nasty 
 discharge, causing discomfort. Pain and bad haemorrhage 
 are usually marked only in the advanced stages. There 
 may be micturition troubles. 
 
 Sarcoma. — This is very rare. It may be round or spindle- 
 celled, or melanotic. 
 
 Differential diagnosis of malignant disease. — The following 
 conditions must be diagnosed from carcinoma and sarcoma : — 
 
 I. Simple tumours. 
 
 I 
 
h 
 
 554 
 
 AFFECTIONS OF THE VULVA. 
 
 n 1 
 
 2. Lupus. I, 
 
 3. Hard and soft chancre. 
 
 4. Papillary growths, warts, or condylomata. 
 Treatment. — The only means of curing the patient is by 
 
 removing the local disease before the inguinal glands are 
 affected. If the glands are even slightly enlarged, the 
 growth should be removed, as well as the inguinal glands, 
 because sometimes the latter, in the early stage of the 
 disease, may be only sympathetically enlarged. If the 
 glands are much enlarged, we cannot hope to remove 
 the whole disease. Sometimes it is justifiable to remove, 
 the vulvar mass, simply to take away the patient's local 
 discomfort. The removal can best be carried out with 
 the knife. 
 
 If removal is out of the question, palliative measures 
 must be employed, e.g. frequent washing with antiseptic 
 lotions, application of iodoform gauze and antiseptic powders 
 to the ulcerations, and the smearing of surrounding parts 
 with borated vaseline. 
 
 Papillary growths, warts, condylomata, vegetations. 
 — In dirty conditions of the vulva, e.g. sometimes in 
 children and in pregnant women, frequently in connection 
 with venereal affections, warty growths may develop on the 
 vulva, perineum, around the anus, or in the vagina. They 
 may be simple or multiple, and may reach a large size in 
 some cases. They are pale or deep red in colour, and 
 often resemble a "cock's comb." They give rise to a 
 discharge, generally foul smelling ; they may become 
 fissured or inflamed. Patients generally complain of smart- 
 ing pains. 
 
 Treatment. — Complete removal is best. This should be 
 carried out even if the woman be pregnant. 
 
 Fibroma, fibrcmyoma, mjrxoma. — These new growths 
 are rare. They are niostly found in the labia majora. 
 
 Lipoma is sometimes found, especially in the mons 
 veneris. 
 
NEIV GROWTHS. 
 
 555 
 
 Enchondroma is very rare. It is sometimes found in 
 the clitoris. 
 
 Cysts of the vulva. — Small cysts are sometimes found 
 in the vestibule, probably of sebaceous origin ; sometimes 
 in the hymen. They may be found at the urethral orifice, 
 possibly due to occlusion of Skene's glands. Sebaceous 
 cysts may occur in the labia majora. In this situation may 
 also be found an encysted hydrocele of the round ligament, 
 blood cysts, dilated lymphatic cysts, dermoids. The most 
 important cystic swellings are those which occur in the 
 Bartholinian or vulvo-vaginal glands. They are the follow- 
 ing :— . 
 
 In one variety the Bartholinian cyst may vary in size 
 from a marble to an egg. It may be singh, ovoid, and 
 smooth, or it may be lobulated. It is mostly on the left 
 side, though it may be right-sided or bilateral. The con- 
 tents may be colourless or yellow mucus, or a mixture of 
 mucus and blood. The duct of the gland, or the gland 
 itself, may be distended. In the former case the swelling is 
 small and near the vagina, into which it projects ; it may 
 discharge from time to time, and refill, in the latter case 
 the swelling usually becomes large, and is more external 
 than the other. Sometimes the skin may be so thinned 
 over these cysts as to make them translucent. 
 
 Etiology. — These cysts arise as a result of vulvitis (mostly 
 gonorrhoeal in origin), which leads to a closure of the duct. 
 
 Symptoms. — Discomfort on walking and in coitus. 
 
 A second variety of cyst is that due to purulent dis- 
 tension of the gland. It may be produced acutely, or 
 as the result of changes in the above-described cyst. 
 
 Physical signs. — In the acutely-formed condition the 
 swelling has all the characteristics of an abscess. It may 
 be surrounded by oedematous tissue, may tend to point, 
 and gives a feeling of fluctuation ; there is much pain on 
 palpation. 
 
 It may burst, usually on the inner surface of the labium. 
 
'I' 
 
 556 
 
 AFFECTIONS OF THE VULVA. 
 
 The suppuration may extend to surrounding tissues, and, 
 rarely, may burrow througn the rectum or perineum. After 
 it bursts, fistulae may remain for a long time ; sometimes an 
 ulceration develops at the seat of rupture. 
 
 When the abscess is slowly produced by pus formation 
 in a pre-existing cyst, there are usually no signs like those 
 found in acute abscess formation. , ^ 
 
 Syftiptoms. — There is discomfort on walking and in 
 coitus, and in the acute condition sharp pains of a dis- 
 tressing nature. 
 
 Differential diagnosis of Bartholinian cysts — 
 
 1. From hydrocele of the round ligament. 
 
 2. From hernia of the ovary. 
 
 3. From hernia of bowel or omentum. 
 
 4. From cyst of the gland, along with hernia. » 
 
 5. From other cysts of the labium majus. 
 
 6. From peri-rectal abscess. 
 
 7. From a vaginal cyst. 
 
 Treatment. — In some cases the cyst may be dissected out, 
 the wound being closed with continuous catgut. Where 
 this cannot be carried out, it should be opened, the inner 
 surface destroyed with a cautery, and the cavity stuffed with 
 iodoform gauze and allowed to heal by granulation. 
 
 Venereal affections. — I have already described the changes 
 produced by gonorrhoea {^ide " Vulvitis "). 
 
 The syphilitic hard chancre usually develops after an 
 incubation period of about a month, and appears as a small, 
 red, indurated lump, which often ulcerates. It is generally 
 single, but may be multiple. It usually develops on the 
 labia or nymphae ; sometimes on the clitoris or fourchette ; 
 rarely on the vaginal wall or cervix. 
 
 In secondary syphilis, mucous patches and papular erup- 
 tions may develop on the vulva. v 
 
 In tertiary syphilis, gummata may form and may ulcerate. 
 The inguinal glands in syphilis enlarge somewhat, are very 
 hard, and do not tend to suppurate. 
 
fm 
 
 VENEREAL AFFECTIONS. 
 
 557 
 
 Soft chancre usually develops within twenty-four hours 
 after infection. It begins as a small vesicle or pustule, 
 which gives rise to a spreading ulcer with a yellow base and 
 a sharp, red edge. It discharges freely, and in weakly women, 
 e.g. the alcoholic, it may slough or assume a phagedaenic 
 form. They are generally multiple. The inguinal glands 
 usually inflame and tend to suppurate. 
 
 Wounds of the vulva. — Vide p. 558. 
 
 Hernia into the vulva. — Hernia is sometimes met with. 
 It may be omental, intestinal, or a combination of these. 
 Femoral is more common in women than inguinal hernia. 
 There is one rare form in which the hernia descends 
 posterior to the broad ligament, between the rectum and 
 vagina, and extends into the labium or perineum j this 
 form may be readily mistaken for a Bartholinian cyst. In 
 another rare form, the hernia may descend in front of the 
 broad ligament between the bladder and vagina and bulge 
 into the labium. 
 
 \\ 
 
 \- fr 
 
 '- ty 
 
CHAPTER XIX. 
 
 INJURIES AND DISPLACEMENTS OF THE 
 PELVIC FLOOR. ^ 
 
 Wounds of the vulva and vagina. — These may be pro- 
 duced as a result of coitus, parturition, or injuries. 
 
 The first coitus usually tears the hymen, though it may 
 not. Often the tear is only slight. It may, however, 
 extend into the vestibule, labia minora, labia majora, or 
 vaginal wall. Sometimes the whole hymen may be torn off. 
 Rarely the peritoneum may be opened. These violent rup- 
 tures take place when coitus is very forcible, when there is 
 much disproportion between the penis and introitus vaginie, 
 or when the female parts are brittle, as in old age. 
 
 During labour the hymen is stretched and torn in a 
 primipara. The vagina is often slightly torn in its lower 
 part ; sometimes it may be badly lacerated. The condi- 
 tions favouring severe vaginal lacerations are brittleness, 
 dryness, and toughness, as sometimes found in old primi- 
 parae ; cicatricial changes in the wall, resulting from past 
 operative procedures, or inflammation ; where there is 
 obstruction in labour owing to dystocia on the part of the 
 child or hard passages ; artificial delivery, e,g. the use of 
 forceps. Sometimes not only the vagina, but the bladder, 
 rectum, or peritoneum may be opened into ; in some cases 
 the paravaginal tissue may be badly torn ; lacerations 
 produced in labour are most usually on the posterior 
 vaginal wall, on one side of the middle line. As a result 
 of tears, atresia or stetiosis may follow {vide p. 5 90). 
 
 (\ 
 
RUPTURE OF THE PERINEUM. 
 
 559 
 
 Symptoms. — Haemorrhage is produced, and may be very 
 severe. If septic infection of the wound occur, severe 
 inflammations may be set up. 
 
 If the bladder or rectum be opened, the symptoms due to 
 these lesions develop {^oide pp. 622, 643). 
 
 Treatment.— '^Xx^X. tears require no treatment save careful 
 antiseptic douching. Bad tears require immediate arrest of 
 haemorrhage and repair of the wound by aseptic operative 
 measures. For the treatment of atresia and stenosis, vide 
 p. 596, and for that of vesical and rectal fistulae, pp. 623, 643. 
 
 Rupture of the perineum. — This injury is produced 
 during labour. In almost all labours the hymen is torn ; 
 sometimes the fourchette is un- 
 injured, but generally it, along 
 with the anterior margin of the 
 perineum, is lacerated. In some 
 cases the perineum is more or 
 less deeply torn mesially, some- 
 times into the anus. Rarely it 
 may tear from the centre out- 
 wards. 
 
 Sometimes the subcutaneous 
 tissues of the perineum are lacer- 
 ated, the skin being left intact. 
 
 Central rupture rarely occurs. 
 The child may sometimes be born through the rent. I 
 have known this brought about by the accidental cutting 
 of the perineum with a scissor blade as the head bulged 
 it down. 
 
 Etiology. — The following conditions lead to rupture : — 
 Large head or body of a child ; precipitate labour ; rigidity 
 of tissues, due to disease or as found in old primiparae ,; 
 improper use of instruments ; introduction of hand through 
 the vaginal orifice without careful dilatation ; delivery of 
 occif ito-posterior cases in which the occiput is posterior, or 
 of face cases in which the ' in has rotated to the back ; 
 
 Fig. 212. — Complete rupture of 
 the perineum in^o the anus. 
 
 \ 11 
 
 ■^1 
 \ Hi 
 
 \> 
 
 1 [1 
 
 \}- 
 
 11 
 
 I 
 
560 
 
 INJURIES OF THE PELVIC FLOOR. 
 
 narrow subpubic angle ; straight sacrum ; excessive antero- 
 posterior measurement of perineum. 
 
 Results of rupture. — Incomplete rupture tends to close 
 somewhat, healing by granulation, the perineum being left 
 shorter than before the labium. Complete rupture very 
 rarely tends to heal in this way. The existence of an 
 imperfect perineum is one of the factors which tend to 
 bring about a downward displacement of the pelvic floor 
 
 {vide p. 567). If the anus 
 ^ be opened into, there is 
 partial or total incontinence 
 of faeces, varying according 
 to the amount of destruc- 
 tion of the anal sphincters. 
 Treatment. — Immediate 
 rupture. — When this oc- 
 curs, during delivery of the 
 child, repair should be per- 
 formed at once, unless the 
 tear is a very slight one. 
 
 The raw surface is closed 
 by a continuous catgut 
 suture (No. 3) applied from 
 the bottom of the wound 
 to the superficial parts. 
 Plenty of tissue should 
 be pierced by the needle, 
 in order that in the soft- 
 ened condition due to pregnancy it may not tear. 
 
 Old-standing rupture. — {a) Where the anus is not included 
 in the rupture. 
 
 The following operation is the best : — 
 
 The patient is placed in the lithotomy position, having 
 
 been carefully prepared beforehand. With a pair of 
 
 angled scissors a horseshoe-shaped cut is made between 
 
 the anus and introitus vaginae, the sides of the 
 
 Fig. 213. — Operation for repair of 
 incomplete rupture of perineum. 
 The line of incision is shown. 
 
 \\ 
 
 ! \ 
 
RUPTURE OF THE PERTNEUM. 
 
 Id 
 
 e, 
 ft- 
 
 id 
 
 S6l 
 
 labia 
 
 incision running on the inner surfaces of the 
 majora. 
 
 The incision is extended into thj tissues for nearly an 
 inch. The anterior flap is then drawn forwards by a vol- 
 sella, which grasps it in the middle line. The edge of the 
 posterior flap is pulled backwards by a volsella attached in 
 the middle line. 
 
 In this way a gaping, lozenge-shaped, raw surface is 
 produced. This is closed 
 from side to side by a 
 continuous catgut suture 
 (No. 3), carried in several 
 stages from the deepest 
 portion of the wound to 
 the skin surface. The 
 parts are dried and an 
 iodoform suppository is 
 placed in the vagina. 
 Antiseptic powder is 
 sprinkled over the vulva, 
 and a pad of gauze placed 
 over the wound. A mor- 
 phine suppository is given 
 per rectum, and the 
 patient put to bed. 
 
 After-treatment. — The 
 urine is drawn off every 
 six hours for four days. 
 The vulva is washed with 
 antiseptic lotion each day, 
 antiseptic powder being sprinkled over the perineum, 
 and a gauze pad placed there afterwards. An iodoform 
 suppository is placed in the vagina daily. Between the 
 second and third week the patient is allowed to rise. 
 
 ip) Where the anus is involved in the rupture, or at 
 least the sphincter apparatus. 
 36 
 
 Fig. 214. — Operation for repair of 
 incomplete rupture of perineum. 
 The vaginal flap is carried for- 
 wards somewhat to expose the 
 raw surface made by incision. 
 
 
 i i 
 
562 
 
 INJURIES OF THE PELVIC FLOOR. 
 
 A lateral incision is made through the skin on each side, 
 extending from the torn end of the external sphincter 
 forwards on the inner margin of the labium majus for an 
 inch or slightly more. Then another incision is made with 
 sharp, angled scissors into the lower or free edge of the 
 recto-vaginal septum. These incisions are then deepened. 
 
 ; ,>\ ( 
 
 Fig. 215. — Operation for 
 repair of incomplete 
 rupture of perineum. 
 The vaginal flap is car- 
 ried farther forwards. 
 
 Fig. 216. — Opera- 
 tion for repair of 
 incomplete rup- 
 ture of perineum. 
 Appearance of 
 perineum at end of 
 operation. 
 
 They result in the formation of four flaps, two anterior or 
 vaginal, and two posterior or anal. 
 
 These are held at the corners with artery forceps, while 
 the raw surface is incised as much as is thought necessary. 
 The vaginal flaps are then turned forwards and the anal 
 backwards, so that the large quadrilateral raw surface is 
 
 I x 
 
T 
 
 RUPTURE OF THE PERINEUM. 
 
 sfii 
 
 exposed, in the lower angles of which the torn ends of the 
 external sphincter are found. 
 
 The anterior or vaginal flaps are next brought together in 
 the middle line by a few catgut sutures tied on the vaginal 
 surface. The posterior or anal flaps are- also stitched 
 together in the middle line by several catgut sutures tied 
 on the bowel surface. The quadrilateral raw surface is then 
 closed from side to side by a continuous catgut suture 
 applied in severijl stages, ^j, 
 
 great care being Vaken to 
 approximate the torn 
 sphincters. At the end 
 of the operation a new 
 perineum exists, the anus 
 has been repaired, and 
 the introitus vaginae 
 diminished. 
 
 After-treatment. — The 
 same as after the last 
 operation. 
 
 On the fourth day a 
 saline aperient should be 
 given, olive -oil or glycer- 
 in being injected into the 
 rectum carefully before 
 the bowels move. There- 
 after, on the second day, 
 a little opening medicine 
 should be given. The patient lies in bed for about eighteen 
 or twenty days ordinarily. If suppuration has occurred, so 
 that healing is longer delayed, she must rest for a long 
 period. 
 
 Iiijuries to fasciae and muscles of the pelvic floor. — 
 Beside the outward tears produced by labour which I have 
 just described, there are produced probably rather frequently 
 solutions of continuity or permanent stretching in the fascial 
 
 Fig. 217. — Operation for repair of 
 complete rupture of perineum. The 
 line of incision is shown. 
 
 
 1: 
 
 
 } 
 
 
 J, 
 
 7 
 
 -i 
 
 * '' ' 
 
 ■j 
 
 
 
 
 ■ 
 
 .1 . 
 
 i* 
 
 ■ 
 
 .s 
 
 II 
 
 
V 
 
 564 
 
 INJURIES OF THE PELVIC FLOOR. 
 
 and muscular structures of the floor, especially in the former. 
 I have already stated that this may take place In the 
 perineum without any external lesion, this structure being 
 left after labour as a thin, weak septum, which may become 
 a factor in the production of a downward displacement 
 of the floor just as if there had been a complete laceration. 
 
 It is, therefore, not difificult 
 to believe that similar re- 
 sults may be produced in 
 other parts of the p Jvic 
 floor as a consequence of 
 the great stretching which 
 takes place in labour. 
 Stra'. Skene, and Kelly 
 have given some attention 
 to this subject, but we are 
 not in possession of very 
 definite information regard- 
 ing it. 
 
 Fig. 218. — Operation for repair of 
 complete rupture of perineum. 
 The rectal flaps have been turned 
 down and sutured together ; the 
 
 Downward Displace- 
 ments OF THE Pelvic 
 Floor. 
 
 Prolapsus uteri. — Na- 
 ture and 7?iechanism. — For 
 
 vaginal flaps have been turned ^^ny years Berry Hart's 
 
 forwards and sutured together. A . .^ . 1 
 
 large lozenge-shaped raw surface ^lews aS tO the nature 
 
 is thus left exposed. This is closed and mechanism of prolap- 
 
 from side to side with continuous g^g ^teri have occupied a 
 
 catgut suture. • , , • -n •.• \, 
 
 prominent place m British 
 
 gynecology. While he has done the greatest service in 
 
 establishing the hernial nature of the affection, I think 
 
 that his explanation as to the mechanism by which the 
 
 condition is produced is open to serious criticism. 
 
 His description of the nature and mechanism of this 
 
 ( H 
 
PROLAPSUS UTERL 
 
 565 
 
 affection is based chiefly upon the view of the pelvic floor 
 obtained by a study of coronal and transverse sections. 
 Examined in this way, he finds that a ring of loose con- 
 nective tissue can be traced in the pelvic floor, running in 
 the following direction : — Beginning behind the i)ubes as the 
 retropubic fat, it passes back on each side, on the inner 
 aspect of the obturator internus and upper portion of the 
 levator ani, and then between the posterior vaginal and 
 anterior rectal wall. This ring divides the pc 'ic floor 
 into — 
 
 (<?) The entire displaceable portion^ consisting of bladder, 
 urethral and vaginal walls, with the uterus and appendages 
 resting upon it. 
 
 {b) The entire fixed portion^ consisting of all outside the 
 inner aspect of the levator ani and all behind the posterior 
 aspect of the posterior vaginal wall. 
 
 The loose tissue between these is a line of weakness. 
 
 The entire displaceable portion is supported by the entire 
 fixed portion. In prolapsus uteri the former is driven down 
 past the other, this line of weakness forming the "line of 
 cleavage " between the two. 
 
 Is Hart's division of the pelvic floor n this way in keeping 
 with the anatomical details furnished by dissection ? Does 
 such an important line of weakness exist in the pelvis? 
 Yes, if we leave out of consideration the pelvic fascia, as Hart 
 has done. There is no doubt whatever that there is in the 
 pelvis, as 1 have already pointed out, loose tissue behind 
 the pubes, at the sides of the bladder, vagina, and rectum, 
 and between the upper part of the vagina and the rectum. 
 Hart's description, however, gives one the erroneous impres- 
 sion that this tissue is the sole link between the structures 
 internal and those external to it, and that because of its 
 weakness it is possible for the internal to slide down upon 
 the external. The important structur'^^ which have been 
 overlooked are the visceral layers of th».i pelvic fascia, form- 
 ing ligaments for bladder and urethra, for vagina and rectum. 
 
 
 'if 
 
 lis 
 
566 
 
 INJURIES OF THE PELVIC FLOOR. 
 
 as well as the triangular ligament, the deep superficial fascia 
 and the anal fascia which blend with one another in the 
 perineum, and also with some of the visceral layers, thus 
 binding together inferiorly the structures described as 
 " entire displaceable," and those described as " entire fixed." 
 Verily, the pelvic floor described without the pelvic fascia 
 ranks on the same footing as a house described without 
 foundations, girders, or rafters. 
 
 It is as if we were to make a transverse section of a barrel 
 between the hoops, and then to describe the whole barrel as 
 consisting of a series of cylindrically arranged staves (without 
 reference to the very important, though few and small, hoops). 
 
 The truest idea of the pelvic floor is gained when we con- 
 sider it as having a strong fascial framework in which are 
 suspended bladder, vagina, uterus, and rectum, and having 
 in connection with it certain muscular structures which give 
 additional strength. The floor as a whole thus resists intra- 
 abdominal pressure, the anterior and posterior parts of the 
 floor being intimately connected by the fascial and muscular 
 tissues. Anatomically, therefore, it can be proved that the 
 so-called " displaceable portion " does not merely rest on the 
 " fixed portion " in such a manner as that when the support 
 of the latter is gone the former falls down. Clinically also, 
 it seems to me, the facts are against this view. Many cases 
 of perineum ruptured even into the anus are not followed by 
 prolapse j whereas, if Hart were correct, in every case, owing 
 to the loss of support, this should immediately occur. 
 
 Prolapse of the bladder, urethra, and vagina, with the 
 uterus, in reality, it will be found, depends upon the power 
 that the fascial and other tissues, suspending them between 
 the bony pelvic walls, possess of resisting intra-abdominal 
 pressure. If the former be weakened, or the latter increased, 
 or both these conditions be combined, prolapsus occurs. 
 
 The nature and mechanism of prolapsus uteri is still a 
 very disputed question. There are certain points, however, 
 which are granted by everybody. These are as follows : — 
 
PROLAPSUS UTERI, 
 
 567 
 
 .Prolapse may be acute, subacute, or chronic \ the last is 
 by far the most common variety, and is the form ordinarily 
 referred to under this term. It is extremely rare in women 
 who have never been pregnant. It is rare in women who 
 are in good circumstances and lead a comfortable life, even 
 though they are multiparae. It is common among poor, 
 hard-working women. 
 
 The influence of pregnancy and labour on the floor is a? 
 follows : — Its tissues are softened and stretched by the in- 
 creased intra-abdominal pressure, as well as during the birth 
 of the child, when it may also be torn. After labour the 
 floor bulges down more because of this stretching. Among 
 the poor, women usually rise too soon from bed and begin 
 too early to do such work as lifting, carrying, etc. Hence 
 the greater tendency to a prolapse of the floor among them. 
 
 What part does the perineum play ? There is no doubt 
 that it is usually found to be more or less ruptured. 
 Thomas, who described the perineal body as a wedge sup- 
 porting the anterior part of the floor, said that the destruction 
 of the wedge resulted in the prolapse. This is no longer 
 believed in. Hart says that rupture of the perineum is 
 rupture of the "entire fixed segment," and that thus the 
 "entire displaceable " portion can be driven down more 
 easily. That rupture of the perineum favours prolapse when 
 other causes are in operation is undoubtedly true. It does 
 so, however, not because a supporting wedge is removed, 
 acccording to Thomas, nor because a supporting segment of 
 the floor is weakened. These mechanical explanations are 
 not in keeping, as I have shown, with the anatomy of the 
 floor. Neither is it, as is so often said, because the junction 
 of the levatores ani is torn through. In an ordinary mesial 
 tear passing even into the anus, only a small part of the 
 pubo-coccygeus can be torn, namely, those fibres which are 
 deflected inwards to the perineum from the main mass of 
 the muscle which passes back on each side of the middle 
 line to the coccyx. The most important structures torn 
 
V. 
 
 568 
 
 INJURIES OF THE PEL VIC FLOOR. 
 
 V 
 
 through are the various fascial tissues which meet in the 
 perineum — a point which has been entirely overlooked. 
 These are the following : — 
 
 1. Triangular ligament — anterior and posterior layers. 
 
 2. Recto-vaginal visceral layer. 
 
 3. Anal fascia. > , ;j . * 
 
 4. Deep superficial fascia. ' 
 
 It is evident that such a rupture must lead to a weakening 
 of the suspensory framework of the floor, especially in its 
 anterior half, i ■ «-, , ; 
 
 The tearing of the small muscles, e.g. transversus perinei 
 profundus, transversusperinei, sphincter vaginae, and sp' ' 'ter 
 ani, gives them afterwards but a small share in the . jort 
 of the floor, though their loss is of minor importance when 
 compared with that of the fascial structures. 
 
 In many women, chiefly among the well-to-do, who 
 undergo little physical exertion, these losses may be present 
 for a long time and yet no prolapse occur. This is because 
 the rest of the suspensory framework is sufficient to resist 
 the normal intra-abdominal pressure. If in such, however, 
 chronic bronchitis supervene, the result may be that a pro- 
 lapse occurs because the intra-abdominal pressure is too 
 strong for the weakened floor. It is well known that there 
 may be congenital deficiency of the perineum without pro- 
 lapsus. One interesting case is recorded by Prochownik, in 
 which a girl lived in this condition until she was nearly 
 twenty. She then, however, was put to very hard physical 
 exertion for seven months, and the result was a prolapse. 
 
 Now as to the nature of the prolapse. Hart says that the 
 uterus has nothing to do with it, the condition being really a 
 hernia of which the uterus forms part of its covering. 
 Schultze, on the other hand, in his classical work on the 
 subject, says that the essential part of the affection is a 
 descent of the whole uterus, the direct cause being the 
 relaxation of its essential attachments — the utero-sacral liga- 
 ments, giving rise to the retroversion, which is always, 
 
PROLAPSUS UTERI. 
 
 569 
 
 according to him, the preliminary stage of a prolapse. Hart 
 does not mention the utero-sacral ligaments as having any 
 part to play whatever, and he says that the retroversion 
 occurs during the progress of the prolapse. 
 
 Hart says that, first of all, the floor in front of the anterior 
 rectal wall is driven down — the anterior vaginal wall from 
 below upwards, followed by the uterus, and then by the 
 posterior vaginal wall from above downwards. Tension 
 on the cervix is caused, and hence retroversion results. 
 Schultze, however, says that the displacement backwards 
 which results from relaxation of the utero-sacral folds leads 
 to the prolapse of the anterior vaginal wall, not the latter to 
 the former ; this displacement diminishes to one-half or one- 
 third the distance which previously separated the uterine 
 and pelvic insertions of the vagina, and so forces the anterior 
 vaginal wall with the bladder to bulge into the lumen of the 
 canal. He thinks that the part which the anterior vaginal 
 wall plays in dragging down the uterus is over-estimated ; 
 though not proven, he says that it is most probable tha; the 
 first descent of the uterus is not thus brought about. 
 
 These differences of opinion are certainly very great. The 
 exact truth is, I believe, to be found midway between them. 
 The mechanism is not the same in all cases. 
 
 1. Prolapsus in early life is rare, but when it does occur 
 it is undoubtedly a condition connected with weakening of 
 the floor. In fact, the whole floor may be prolapsed, e.g. 
 as in a case of a child, recorded by Breisky, where bladder, 
 vagina, uterus, perineum, and rectum were prolapsed. Pro- 
 lapsus of the uterus alone in childhood is undoubtedly one 
 of the rarest conditions, though it and the vagina are more 
 favourably placed than in the adult condition, being more 
 vertical in the pelvis. 
 
 2. Prolapsus u(eri may occur, the uterus remaining ante- 
 verted or anteflexed. Even Schultze admits this, though he 
 says it is rarely met with. Breisky figures a case by 
 Schroeder. 
 
 ^: i 
 
 I. 
 
570 
 
 INJURIES OF THE PEVLIC FLOOR. 
 
 (In fairness, however, it must be said that possibly the 
 anteverted position was brought about, in these cases, after 
 the prolapse had been completed.) 
 
 There ciin be little doubt that prolapse with the uterus 
 lying anteverted can only be referred to weakening of the 
 floor. In a normal condition of the floor with the uterus 
 lying to the front, Schultze himself says that the intra- 
 abdominal pressure only tends to make the organ more 
 decidedly anteverted, and that this opposes a tendency to 
 prolapse ; abnormal anteversion, he says, is an absolute bar 
 to its occurrence. . ' 
 
 3. Most cases of prolapse undoubtedly have the 
 mechanism described by Hart, i.e. the anterior vaginal wall 
 and bladder descend first, the lowest part appearing first, 
 followed by the cervix, and lastly by the posterior vaginal 
 wall, its lowest part appearing last. i 
 
 Against Hart's views are the following facts — 
 
 1. Prolapse may occur more or less rapidly in nulliparae 
 where the pelvic floor has hitherto been sound and strong, 
 as a result of falls or sudden lifts of heavy weights, etc. 
 
 2. Cases of traumatic retroversion in nulliparae have 
 been sometimes found to be followed by prolapse of the 
 uterus. ,' 
 
 3. In some cases of chronic prolapsus the anterior vaginal 
 wall does not descend first, but the uterus, dragging after it 
 the vaginal walls. 
 
 4 Cases of cystocele are not necessarily accompanied by 
 prolapse of the uterus. 
 
 The only satisfactory manner in which these differences 
 can be explained is by admitting that there are various kinds 
 of prolapsus in the pelvic floor. My conclusions I would 
 state in the following propositions : — 
 
 I. The pelvic floor, as a whole, is a suspensory structure 
 closing the outlet, having let into its substance bladder, 
 urethra, vagina, uterus, and rectum. It is in this way 
 weakened. 
 
PROLAPSUS UTERI. 
 
 571 
 
 2. The floor may be prolapsed as a whole (rarely), as in 
 children — due to weakness of the floor as a whole. 
 
 3. The anterior vaginal wall and bladder may prolapse 
 alone (cystocele), due to weakness of their supports. 
 
 4. The posterior vaginal wall may alone prolapse on 
 account of weakening of its connections. 
 
 5. The posterior vaginal wall and anterior rectal wall may 
 together prolapse (rectocele), due to weakening of their 
 supports. 
 
 6. The uterus alone may be the first to prolapse, dragging 
 after it the parts of the floor attached to it. It must not be 
 forgotten that the uterus has less strong attachments to the 
 rest of the floor and to the bony wall than either the bladder, 
 vagina, or lower part of the rectum. It has no strong 
 fascial layer attaching it to the pelvis. Its connections are 
 more elastic in nature than those of the other structures 
 mentioned, and they may alone become weakened. Retro- 
 version or retroflexion usually results primarily from this. 
 If the retro-displacement be partial, so that the uterus lies in 
 line with the long axis of the vagina, the position is favour- 
 able to the prolapse. If, however, the fundus be driven 
 farther back, so that a marked retro-displacement is pro- 
 duced, the tendency to prolapse is removed (Schultze). 
 
 7. In the majority of cases of prolapse we have to do 
 with a descent of the anterior part of the floor in which 
 the bladder, vagina, and uterus participate. These are the 
 numerous cases which occur in working women vho have 
 had their pelvic floor damaged during labour, who rise too 
 soon from bed, go to work too soon, and perform duties 
 which increase their intra-abdominal pressure. 
 
 The condition produced is, indeed, a hernia of a consider- 
 able part of the floor. The question as to whether the 
 uterus drags down the anterior vaginal wall and bladder, or 
 these structures the uterus, or which is the first to be pro- 
 lapsed, is of secondary importance. In the puerperium the 
 attachments of all these structures are weakened as a result 
 
 If: 
 
 i \ 
 
 ; 
 
 ■5 
 
 
V. 
 
 57a 
 
 INJURIES OF THE PELVIC FLOOR. 
 
 
 of previous softening, stretching, or tearing ; further, the 
 uterus is usually retro-displaced during the latter part of this 
 period. Increased intra-abdominal pressure tends to drive 
 down the weakest part of the floor, the part which is most 
 dependent, i.e. the lower part of the vagina making its 
 appearance first beyond the normal pelvic-floor projection, 
 in almost every case. This is what one would expect from 
 the study of the puerperal pelvis. My sections show that 
 after labour there is usually some bulging of the lower part 
 of the vagina and bladder. This is a very common clinical 
 observation also. That the lower part of the posterior 
 vaginal wall is the last to appear is to be explained by its 
 firm attachment to the other tissues of the perineum. 
 
 It 
 
 Resump^ of the Factors Concerned. ', 
 
 1. Rupture of the pelvic floor. — I have pointed out that 
 the most important rupture is that of the perineum. It is 
 possible that occasionally rupture of fascial and muscular 
 structures in other parts of the floor occurs. 
 
 2. Weakness in parts of the floor. — Though actual rupture 
 may not have occurred, permanent weakness may be in- 
 duced by the great stretching of parts in labour, and may 
 affect fascial structures, muscle, cellular tissues, and liga- 
 ments. . - ■- 
 
 As the uterus enlarges also from metritis it tends some- 
 what to weaken its attachments. . ' 
 
 3. Increase in the intra-abdominal pressure. — This may 
 abnormally affect the pelvic floor. It is due to various 
 causes. In pendulous belly it may be produced, owing to 
 the sinking downwards of the intestines. Chronic coughing 
 may lead to it ; also tumours or ascites in the abdomen ; 
 too tight constriction of the body by the clothing; extra 
 muscular efforts, e.g. lifting, carrying ; habitual over-disten- 
 sion of bladder and bowel. In faults in the bony pelvis, as 
 A. R. Simpson points out, in which the brim becomes more 
 
THE FACTORS CONCERNED. 
 
 573 
 
 Fig. 219. — Prolapsus uteri. 
 
 or less parallel to the horizon, downward displacements of 
 the uterus are favoured, the intra-abdominal pressure acting 
 forcibly and directly on the floor 
 Complications. — The uterus, 
 besides changing its position, 
 as I have described, hyper- 
 trophies. 
 
 The whole organ may be 
 enlarged, or the cervix may 
 especially become elongated. 
 Endometritis or endocervicitis 
 is often present. Cancer is 
 sometimes developed on the 
 cervix, but very rarely. 
 
 The vaginal wall is often some- 
 what inflamed. In complete pro- 
 lapse it loses its rugosities, thick- 
 ens, and becomes skin-like. It may be eioded or ulcerated ; 
 sometimes epithelioma may develop at these patches. 
 
 The bladder is prolapsed be- 
 low the level of the meatus, and 
 cystitis may develop in the 
 diverticulum thus formed ; cal- 
 culus may result from this. 
 
 The rectum may be irritated, 
 especially if a rectocele form ; 
 faecal matter may lodge in the 
 latter. Sometimes pi olapsus 
 recti may exist. Ordinarily there 
 is no rectocele, the posterior 
 vaginal wall having peeled from 
 the gut. 
 
 The appendages are dragged 
 downwards. Peritonitis may 
 occur, forming adhesions in the hernial sac and among the 
 viscera, rendering it dangerous to attempt reposition. 
 
 Fig. 220. — Prolapsus uteri. 
 The cervix is considerably 
 thickened. 
 
 i ; , 
 
V, 
 
 574 
 
 INJURIES OF THE PELVIC FLOOR. 
 
 J 
 
 ry^ 
 
 Physical signs in prolapsus uteri. — It is evident that 
 many different conditions may be found, varying according 
 to the degree of the prolapsus. 
 
 If the condition be partial, the lower part of the anterior 
 vaginal wall bulges downwards when the patient is in the 
 erect position or when she coughs or presses down ; the 
 cervix is lower than normal, and this may cause the posterior 
 fornix to appear abnormally deep. The uterus is enlarged 
 and lies with its long axis in line with the vagina. If the 
 
 prolapsus be complete, the 
 true hernial nature of the 
 affection is readily understood, 
 the sac of the hernia being 
 the peritoneum ; its bound- 
 aries the pubes, anterior rectal 
 wall, obturator internus, and 
 levator ani muscles ; its cover- 
 ings, bladder, anterior and 
 posterior vaginal walls and 
 uterus ; in the hernial sac are 
 intestines. The parts may be 
 far below the level of the 
 pelvic-floor projection. If 
 uiey are replaced, they may be 
 prolapsed, when the patient 
 rises or when she coughs or 
 bears down. The uterus may 
 be considerably enlarged ; the vaginal walls over it may be 
 much hypertrophied and ulcerated or excoriated. The 
 sound may be passed into the cavity. A catheter or sound 
 passed into the bladder distinguishes the prolapsed portion. 
 A finger passed into the rectum makes out whether there is 
 or is not any rectocele. 
 
 Symptoms of prolapsus uteri. — The patient has a feeling 
 of dragging and weight in the loins or pelvis. When the 
 uterus is outside, or partly outside, she feels discomfort. 
 
 Fig. 221. — Complete prolapsus 
 uteri. A sound is passed into 
 the bladder to show its rela- 
 tion to the prolapsed mass. 
 
THE FACTORS CONCERNED. 
 
 575 
 
 There may be difficulty in micturition, or frequency. 
 Symptoms of cystitis and of stone may develop. Diar- 
 rhoea or difficulty in defaecation may exist. Menorrhagia 
 is often present, due to the associated endometritis. Leu- 
 corrhoea may arise from the same cause, from endocervicitis 
 or from irritation of the vaginal walls. As a rule there is 
 sterility ; but conception may occur, and there may be much 
 discomfort in the early months. 
 
 Differential diagnosis. — The condition must be diagnosed 
 from hypertrophic elongation of the cervix, cystocele, recto- 
 cele, inversion of the uterus, polypus of the uterus, polypus 
 with inversion, swelling of the pudenda. 
 
 Prognosis. — When once a prolapsus is established, it 
 shows no tendency to recover 
 itself. It may be modified by 
 pregnancy. During the first 
 three months the uterus tends 
 to sink down more markedly, 
 and abortion may occur. If 
 the womb be supported during 
 this period until it has begun 
 to rise above the brim, there 
 is usually no trouble during the 
 rest of pregnancy. Occasionally 
 a slight case may, after a long 
 
 ^ . ^, . ^ 1 ^ Y\G. 222. — Cystocele. 
 
 rest m the puerperium, tend to 
 
 be restored. Often, however, the condition is aggravated 
 
 after labour. 
 
 The condition may be also modified by the menopause. 
 The parts undergo some degree of atrophy, and there may 
 be some relief in symptoms. Often, however, the prolapse 
 becomes more marked. 
 
 Diagnosis of cystocele. — There is a pouching downwards 
 of the anterior vaginal wall and bladder, the uterus and 
 posterior vaginal wall being undisturbed. The patient may 
 complain of something falling down, or may feel discomfort. 
 
576 
 
 INJURIES OF THE PELVIC FLOOR. 
 
 It is aggravated on coughing or straining. There may be 
 trouble in micturition. 
 
 Diagnosis of rectocele. — The lower part of the anterior 
 rectal wall bulges forward with the posterior vaginal wall. 
 This is especially apt to occur if there be a marked tear of 
 the perineum. The uterus and anterior vaginal wall are in 
 position ; sometimes a cystocele may exist with it. The 
 finger passed into the rectum feels the pouching. Faeces 
 are apt to collect in it. 
 
 Diagnosis of vaginal enterocele. — Anterior or posterior 
 enterocele may occur. In the first-mentioned the intestines 
 are forced downwards between the upper part of the vaginal 
 
 wall and the bladder, bulging the 
 former into the vaginal canal. 
 In the last-mentioned the intes- 
 tines descend between the rec- 
 tum and vaginal wall, and bulge 
 the latter into the vaginal canal. 
 On passing the sound the 
 bladder is found to be in posi- 
 tion, or perhaps pushed some- 
 what forwards in anterior 
 enterocele. In posterior entero- 
 cele the exploring finger makes 
 out that there is no rectocele. 
 Treatment. — Prophylaxis is important. Labours should 
 be conducted carefully. Ruptures should be restored at 
 once, or as soon as possible afterwards. The patient should 
 not be allowed to rise too soon or to work too early. 
 Actual treatment is carried out on the following lines : — 
 The prolapsed condition should be reduced first of all. 
 Sometimes in bad prolapsus uteri the parts are so swollen 
 that it is necessary to put the patient to bed for a few days, 
 during which time she should get the hot douche and hot 
 hip-baths. Where there is peritonitis it may be dangerous 
 to replace the parts. Antiphlogistic measures should be 
 
 Fig. 223. — Rectocele. 
 
THE FACTORS CONCERNED. 
 
 $77 
 
 carr'f^d out, and efforts to replace the parts made slowly and 
 cautiously. 
 
 If reduction is carried out, various forms of treatment 
 may be employed. But in all cases inflammatory com- 
 plications should be attended to. Where there is anterior 
 enterocele or cystocele alone, a ring, a diaphragm ring, a 
 Hodge pessary with transverse bars, or a globular or egg- 
 shaped pessary, may be introduced into the vagina to 
 retain the parts. If the perineum be ruptured, only the 
 ring pessaries should be used, and even they may not be 
 retained. 
 
 When a pessary fails to support the prolapsing part, an 
 operation should be tried. The most thorough method is 
 to perform an anterior colpotomy without opening into the 
 peritoneal cavity if possible, rawing the anterior surface of 
 the cervix and the posterior wall of the bladder, and then 
 stitching them together. An oval-shaped flap of the anterior 
 vaginal wall, extending from near the anterior fornix to near 
 the urethral orifice, should then be removed, and the raw 
 surface closed by continuous catgut sutures. Care must be 
 taken not to injure the ureters. When there is posterior 
 enterocele or rectocele alone, retention by means of the 
 same pessaries may be tried. When they fail, operative 
 measures must be employed. 
 
 In the former condition the following measure should be 
 adopted : — 
 
 A vertical mesial incision should be made in the posterior 
 vaginal wall, the peritoneum should be stripped upwards as 
 high as possible, and the anterior wall of the anus should be 
 stitched to the vaginal wall, after a portion of the latter has 
 been cut away parallel with the incision. In this way a new 
 recto-vaginal septum is formed. Operation is not very satis- 
 factory in this condition. , ;• - ■ 
 
 In rectocele a posterior colpoperineorrhaphy may be per- 
 formed. Some, however, prefer the above-described pro- 
 cedure. In prolapsus uteri which is slight, the organ is 
 37 
 
 
578 
 
 INJURIES OF THE PELVIC FLOOR. 
 
 usually retroverted. It should be replaced and a Hodge or 
 Albert Smith pessary introduced into the vagina. If these 
 will not remain in place, owing to the tear of the perineum, 
 a ring may be employed or a repair operation may be 
 performed on the perineum, in order that an instrument 
 may be worn afterwards. 
 
 Where the uterus is markedly prolapsed along with more or 
 less of the vaginal walls, a Hodge, ring, ball or Zwanck 
 pessary may be used to support the parts, the choice of 
 
 an instrument depending largely 
 upon the state of the perineum. 
 
 In extreme cases, especially of 
 old standing, no pessary will re- 
 main in the vagina unless it be 
 held by bands. In these cases 
 operative treatment is imperative. 
 Where the patient will not submit 
 to this method, a cup-pessary 
 attached to an abdominal belt, or 
 a T-bandage, may be employed. 
 Sometimes women prefer periodic 
 packing of the vagina with iodo- 
 form gauze or oakum ; this should 
 only be carried out after the 
 menopause. \ 
 
 The operative treatment in these 
 cases is as follows : — 
 After careful preliminary preparation of the patient, she 
 is placed in the lithotomy position. If the uterus is en- 
 larged to any extent (and it usually is in these cases), it 
 should be curetted, and the cervix amputated in order to 
 stimulate the organ to involution. 
 
 Then an anterior colporrhaphy is performed in the follow- 
 ing manner : — The cervix is pulled downwards and back- 
 wards, and held. The anterior vaginal wall is grasped with 
 a volsella above the urethral orifice and held steady. An 
 
 Fig. 224. — Anterior col- 
 porrhaphy in a case of 
 prolapsus uteri. The 
 oval-shaped raw surface 
 on the anterior vaginal 
 wall is shown. 
 
THE FACTORS CONCERNED. 
 
 579 
 
 oval incision is made through the vaginal mucosa as large 
 as is recjuired, the long diameter being in the long axis of 
 the vagina. The size varies according to the degree of 
 prolapse. A vertical incision is made from end to end 
 of the oval through the mucosa, and each lateral flap of 
 mucosa is dissected off until the oval raw surface is left. 
 This is then closed from side to side by a continuous catgut 
 suttre (No. 2 or 3) passed in stages. Next, the perineum 
 should be repaired in the manner described on p. 560. In 
 this way the uterus is made smaller ; the vagina is nar- 
 rowed by the constriction resulting from the colporrhaphy, 
 and a new strong, thick perineum is formed. 
 
 In more marked cases, where the nsterior vaginal wall 
 is much prolapsed and stretched, it is oest after doing the 
 anterior colporrhaphy to perform 
 a posterior colporrhaphy, along 
 with an operation to repair 
 the perineum, e.g. a colpoperi- 
 neorrhaphy. Various methods 
 are employed. The following 
 n y be adopted :— An anterior f,g. aas—Colpoperineorrhaphy. 
 
 spatular speculum is introduced The diagram shows the rawed 
 
 to pull up the anterior vaginal surface made on the posterior 
 
 ,, rr.1 1 • "J J i_ vaginal wall and perineum. 
 
 wall, ihe vulva is widened by 
 
 means of retractors. The middle of the posterior wall of 
 the vagina, about ij in. above the perineum, is held with 
 a vol sella. Below this on each side the lateral edges of 
 the same wall are held with forceps. In this way the 
 lower part of the posterior wall is put on the stretch, 
 Then with a knife an incision is made on the posterioi' 
 vaginal wall and perineum, the outline being that indicated 
 in Fig. 225. The flap is then dissected off, and the raw 
 surface closed from side to side by a continuous catgut 
 suture. The vaginal portion should be closed before the 
 perineal part is stitched. 
 
 After-treatment. — Practically the same as after a tear of 
 
 
 
 i' 
 
 : ri 
 
 
V 
 
 58o 
 
 INJURIES OF THE PEL VIC FLOOR. 
 
 the perineum. In the most marked cases the following 
 operative procedures are recommended by some, namely, 
 shortening of the round ligaments, stitching the uterus to 
 the anterior abdominal wall {vide p. 460). These methods 
 are still on their trial. 
 
 Their necessity or value has not yet been clearly defined. 
 Most arj agreed that they should not be carried out apart 
 from the various operative procedures already recommended, 
 e.g. curetting, amputation of cervix, colporrhaphy, perineor- 
 rhaphy. Their application must be a very limited one, and 
 might be recommended where the other methods used alone 
 fail. 
 
 Very often after these operations no pessary requires to 
 be worn. But sometimes it may be necessary to use one. 
 The improve*! condition of the vagina and perineum will 
 render its employment more satisfactory. \ 
 
 l> 
 
I ';■ 
 
 CHAPTER XX. 
 
 AFFECTIONS OF THE VAGINA AND HYMEN. 
 
 Vaginitis. 
 
 Pathology. — In acute vaginitis the mucosa is swollen and 
 red ; the papillae are markedly hypertrophied, owing to infil- 
 tration of them. The epithelium over them may become 
 thinner owing to shedding, so that the red points are 
 clearly seen like granulations — the so-called granular 
 vaginitis. The discharge is slightly acid or alkaline. If 
 due to gonorrha^a, it is creamy and purulent, gonococci 
 being found in the fluid, the leucocytes, and epithelial cells 
 of the discharge. Sometimes vegetations are found in pro- 
 longed gonorrhoeal attacks. 
 
 In chronic cases, the inflammation may only be found 
 in certain spots, e.^. in the fornices and in the Bartholinian 
 ducts or glands. 
 
 In senile vaginitis, the mucosa is affected in patches 
 which appear red, owing to the shedding of epithelium. 
 They tend to adhere to one another, leading to cicatrisa- 
 tion and shrinkage of the walls. Sometimes the cervix may 
 be completely shut off in this way. 
 
 In diphtheritic vaginitis the wall becomes swollen and 
 covered with the characteristic membrane. The term is 
 sometimes wrongly applied to the condition found in 
 connection with severe septic affections or in the acute 
 exanthemata. 
 
 Exfoliative vaginitis is a condition described by Farre, in 
 
 it 
 
V 
 
 582 AFFECTIONS OF THE VAGINA AND HYMEN. 
 
 which periodic exfoliation of the vaginal epithelium is said 
 to occur, probably associated with menstruation. 
 
 In severe phlegmonous i)erivaginitis the vaginal wall may 
 necrose and be thrown off. 
 
 VVinckel has (les(Tibed a condition known a: emphysem- 
 atous vaginitis, in which little cysts occur containing gas, 
 accompanied with swelling of the parts and a discharge ; 
 this affection has been found mainly among pregnant or 
 puerperal women. 
 
 Etiology. — At the present time the tendency is to regard 
 all forms of vaginitis as dependent upon the action of 
 micro-organisms. Of these, the most common is the 
 gonococcus. There are some who hold that this germ is not 
 specific, but that it is merely one which is found in different 
 cavities of the body, e.g. in the urine (Sternberg and others), 
 taking on pathogenic characters under suitable conditions. 
 This view is probably incorrect, and we may regard it as 
 fairly well established that the gonococcus is pathogenic. 
 Some hold that ordinarily the vagina is not directly attacked, 
 but only the urethral and cervical mucous membranes ; 
 if, however, the vaginal wall becomes lowered in vitality 
 from any cause, or its epithelium at all softened, the 
 microbe may develop in it. In such cases the charac- 
 teristic appearances, described by Neisser, may be seen in 
 the pus discharge, in epithelial cells in the discharge, and in 
 the very substance of the wall. 
 
 As regards the vagina in childhood, there is no doubt 
 that the gonococcus may attack it directly, liumm was the 
 first to state that it could not develop in the stratified 
 squamous epithelium of the vagina, but only in the 
 epithelium lining the urethra and cervix. He placed 
 gonococci in the vagina for twelve hours in several cases 
 without setting up any vaginitis. He also excised a 
 portion of the vaginal wall in a severe case of gonorrhoea, 
 and found, on microscopic examination, no gonococci in it. 
 The swelling and tenderness in the vaginal walls he there- 
 
 \\ 
 
VAGINITIS. 
 
 583 
 
 fore regarded as due to irritation from the vulvar and 
 cervical discharges. Ikimni has, however, since modified 
 these views, and he now believes that occasionally in the 
 adult a true acute gonorrlueal vaginitis may occur, <•.,(,''. 
 when tiie vaginal wall is very delicate, as in early life, or 
 thinned, as in old age. Schwarz, Touton, Dinkier, and 
 others have opposed Bumm's original views. Sanger be- 
 lieves that the vagina is attacked only when its wall is 
 delicate, thin, or impaired in vitality, e.f^. in infancy and 
 youth, in pregnancy and in senile conditions. Mandl has 
 carefully examined excised portions of the vaginal wall in 
 several cases of gonorrha^a. He found the sub-epithelial 
 connective tissue infiltrated with leucocytes and pus cells ; 
 the epithelium was thinned in parts so that the papillai were 
 almost exposed ; in other places it was infiltrated with pus 
 cells. The whole wall was deeply injected, and had a red 
 raw appearance. 
 
 (ionococci were found on the surface and in the entire 
 thickness of the epithelium, many being in the pus cells. 
 In many places they were found in the sub-epithelial 
 connective tissue, having penetrated most deeply where the 
 epithelial layer was thinnest. 
 
 Mandl points out that it is important to examine sections 
 of the vaginal wall in the early stages of the disease. At 
 later periods the dead or degenerating cocci may fail to 
 take on the stains. 
 
 The pathogenic micro-organisms of suppuration may also 
 set up vaginitis if they enter the vagina in sufficient num- 
 bers, and find plenty of discharge in which to develop ; any 
 weakened condition of the vaginal wall is a favouring cause. 
 
 Possibly certain saprophytic organisms may be a cause, 
 under favouring conditions. 
 
 In some cases microbes higher than bacteria may set up 
 vaginitis, e.g. Oidium albicans^ Manila Candida and Lepto- 
 ihrix vaginalis. 
 
 The favouring conditions for the development of vaginitis 
 
 
 ! ! 
 
584 
 
 AFFECTIONS OF THE VAGINA AND HYMEN 
 
 are many. Discharges from the uterus ; these act by soften- 
 ing the vaginal epitheHum, and by affording an alkaline 
 medium in which the microbes may develop. 
 
 Irritation of the vaginal walls from worms, fistulous com- 
 munication with bladder or rectum, from tumours, prolapsus 
 uteri, pessaries, douches, examination, or operative pro- 
 cedures, excessive coitus, masturbation, horseback riding, 
 the use of a sewing-i ichine ; certaia constitutional condi- 
 tions weakening the tissues or causing desquamation of 
 epithelium, e.^. the exanthemata, dysentery, tuberculosis, 
 diabetes. 
 
 Symptoms. — In acute cases there is heat and pain in the 
 vagina ; increased secretion, which may give rise to a 
 pruritus ; pain and frequency of micturition, when the 
 urethra is involved ; pain on coitus. ; 
 
 Where the condition is of the phlegmonous or erysi{>- 
 elatous variety, there may be considerable constitutional 
 symptoms. In chronic cases the discharge is the chief 
 complaint, tho'igh there may be as well pain on coitus. A 
 protracted case may lead to a weakening of the health. 
 
 Physical signs. — On examination in the acute stage the 
 vagina is hot, and the movements of the fingers cause pain. 
 In the granular form the hypertrophied papillae may be 
 felt. Through the speculum the redness of the wall is 
 visible, and the granular condition if it exists. When the 
 urethra is affected, pus may be squeezed from it or from 
 Skene's glands. Generally, also, in gonorrhceal cases, it can 
 be forced from the ducts of the Bartholinian glands. 
 
 Vegetations may be seen in gonorrhceal cases, or in non- 
 gonorrhoeal vaginitis of pregnancy. In the senile form the 
 adhesions may be felt, and the reddish patches may be 
 visible. (It is important to note that a pelvic abscess 
 discharging into the vagina has been mistaken for 
 vaginitis.) 
 
 Prognosis. — In most cases of non-gonorrhoeal inflam- 
 mation, the disease is curable ; the most unfavourable are 
 
 \\ 
 
VAGINITIS. 
 
 58s 
 
 those in which irritation of the vaginal wall is kept up by 
 discharge from cancer of the uterus or from a fistula. 
 
 Gonorrhoeal inflammation is a serious matter, because of 
 the difficulty of curing it, and because of the complications 
 which may follow. 
 
 After a case has been thought to be cured, inflammation 
 may remain in the cervix or Kartholinian glands for a long 
 time. It may affect the whole uterine mucosa, the Fal- 
 lopian tubes, ovaries, and peritoneum. (I have already 
 referred to the question as to whether in these cases the 
 gonococcus acts, or other germs which develop in the 
 secretions due to the gonococcus, vide p. 153). 
 
 In these chronic cases, weakening conditions, c.^. chills, 
 fatigue, the puerperium, may cause a recrudescence of 
 activity in the affection. 
 
 Treatment. — The local irritating cause should be removed 
 and also the weakened conditions. In acute cases the 
 vagina should be douched with corrosive sublimate lotion 
 (i in 3000), carbolic lotion (i in 50), creoline or lysol 
 (i in 100), peroxide of mercury, (i in 5000), salicylic acid 
 (i in 200), formalin (i in 1000). If these cause too much 
 pain, lead lotion or solution of permanganate of potash 
 may be used. 
 
 Hot sitz-baths may also be employed. The patient should 
 rest ; the diet should be simple, and the bowels should be 
 kept freely open. Sometimes morphia is necessary on 
 account of the pain. Copaiba and cubebs are rarely given 
 to women for the urethral affection, being badly borne. 
 When the acute stage is past, the antiseptic douching 
 may be vigorously employed, e,}j;. a mercuric iodide or 
 chloride lotion of i in 2000 to 4000 may be employed. 
 The vagina and vulva may be swabbed with nitrate of 
 silver (3 to 5 per cent.), copper sulphate (2 to 5 per cent.), 
 or crude pyroligneous acid. 
 
 It is also necessary to make a thorough antiseptic appli- 
 cation to the interior of the uterus. In some cases curetting 
 
V, 
 
 S86 AFFECTIONS OF THE VAGINA AND HYMEN. 
 
 of the uterus or removal of a bad patch of endoccrvicitis is 
 advisable. Iodoform pencils may be used in the urethra. 
 Sometimes Skene's glands may require to be cauterised. I 
 have already referred to the carrying out of the same pro- 
 cedure when the duct of the Bartholinian gland is affected. 
 In very old cases, astringents, e.g. douches of alum, copper 
 sulphate, sulphate of zinc, borax, etc., may be used. 
 
 General treatment may be necessary, e.g. iron, tonics, 
 change of air, etc. 
 
 In the sloughing forms of vaginitis it is well, besides 
 using antiseptic douches, to insert plugs of iodoform gauze, 
 so as to keep the walls apart. 
 
 Vaginismus. 
 
 This is an excessive hypersesthesia of the vulva, whereby 
 spasms of muscles occur when coitus is attempted or when 
 the physician tries to make a vaginal examination. In 
 some cases there is hyperaesthesia without contraction. 
 
 Etiology, pathology. — The condition is generally found in 
 young and nervous women. It may be found where no 
 local lesion is present. Generally, however, one or other 
 of the following conditions is present : — Tender carunculce 
 myrtiformes ; unruptured sensitive hymen ; fissures or sores 
 of the vulva or anus ; polypus ; prolapse or caruncle of the 
 urethra. Contractions may occur in the sphincter of the 
 vagina, levator ani, sphincters of the anus, and other 
 perineal muscles. 
 
 Differential diagnosis. — The condition must be dis- 
 tinguished from dyspareunia, imperforate hymen, and 
 atresia vaginae. 
 
 Treatment. — Operative treatment is generally necessary 
 in this condition. If the cause be any local irritation, e.g 
 urethral caruncle — this is removed as described on p. 605 ; 
 if tender hymen or carunculae myrtiformes, these are to 
 be cut away, and the vaginal orifice somewhat stretched. 
 
 \ 
 
VAGINISMUS. 
 
 587 
 
 Fissures around the vaginal orifice or in the anus are 
 to be divided or stretched. 
 
 If no local cause can be discovered, contraction of the 
 sphincter vagi nai occurring reflexly when the [)enctrati()n is 
 attempted, stretching of the vaginal entrance by means of 
 the large Hegar dilators, as well as by the fingers arranged 
 in a cone-shaped mass, should be performed. Or, the 
 fibres of the sphincter vaginae may be cut on each side 
 of the fourchette, the ostium vagina; being afterwards some- 
 what stretched. 
 
 After all of these procedures, a glass tube is worn whue 
 the patient lies in bed, and when she walks about, for two 
 or three weeks after the operation. 
 
 The outer end of the tube has a rim to which are tied 
 tapes. These pass in front and behind the thighs, and are 
 fastened to an abdominal band. 
 
 General treatment may be necessary as well. Sometimes 
 patients get very much run down and even hypochondriacal. 
 
 Tumours of the Vagina. 
 
 Cysts. — Small cysts may be found, sometimes, scattered 
 over the vaginal walls, due, according to Winckel, to in- 
 flammatory changes. 
 
 Larger cysts are also found, varying in size from a bean 
 to a walnut, or even larger. They are mostly found on the 
 anterior wall, but may be found on the posterior. They 
 may be developed from remains of the Miillerian duct, 
 from dilatation of lymphatics, or from extravasation of blood. 
 According to some, they may also arise from remains of the 
 Wolffian ducts (^ide pp. 68, 601.) 
 
 They are usually single, but there may be more than one. 
 Sometimes the cyst may be high up, sometimes low down ; 
 rarely the hymen may form part of the wall. 
 
 The vaginal mucosa may be so thinned over the cyst 
 that it is somewhat translucent. The lining of the cyst 
 
588 AFFECTIONS OF THE VAGINA AND HYMEN. 
 
 may consist of columnar (sometimes ciliated), flattened, or 
 pavement epithelium ; in some cases no epithelial lining 
 can be made out. Kaltenbach and (iraefe have described 
 pai)ilL'e attached to it. The contents vary, and may be 
 clear and viscid, yellowish, turbid, or dark. 
 
 It is possible that sometimes a cyst may be formed by 
 gradual occlusion of the neck of a urethrocele. Sometimes 
 the cyst may be found with a vertical mesial vaginal septum, 
 thus pointing to its Miillerian origin. 
 
 Symptoms. — 'i'here may be no symptoms if the cyst be 
 small. If large, there may be a bearing-down feeling and 
 discomfort in walking. Leucorrhcjea may be caused by its 
 irritation. 
 
 Differential diagnosis. -These cysts must be distinguished 
 from cystocele, urethrocele, rectocele, periurethral cysts, 
 swellings of the labia, swellings external to the vagina, e.g. 
 prolapsed ovaries, inflammatory masses, hydatid, etc. 
 
 Treatment. — 'I'hese should be removed if possible. A 
 longitudinal incision is made through the vaginal mucosa 
 over them. The cyst should then be dissected out, and the 
 raw cavity closed with continuous catgut suture. If a com- 
 munication exists between it and the urethra, the edges 
 should be pared and closed with sutures. 
 
 When high up on the posterior vaginal wall, it may not 
 be possible to dissect it out. Part of the wall may be 
 excised, the lining swabbed with iodised phenol, and the 
 cavity stuffed with iodoform gauze. 
 
 Fibroma and fibromyoma. — These are rare. They are 
 found mostly on the anterior wall, and are sessile or poly- 
 poidal. They may be very adherent to the urethra. 
 
 Diagnosis. — Small tumours may cause no trouble. Larger 
 ones may cause a feeling of weight and discomfort. Leu- 
 corri.C'ja may be present ; micturition troubles may occur. 
 There may be difficulty of coitus. Other symptoms may 
 arise, due to changes in the tumour, e.g. inflammation, 
 sloughing, etc. 
 
 \\ 
 
TUMOURS OF THE VAGINA. 
 
 h»/ 
 
 589 
 
 The condition must be diagnosed from uterine tumours, 
 prolapsus, or inversion of the uterus ; when sloughing or 
 ulcerated it may bj mistaken for malignant disease. 
 
 Treatment. — The vaginal wall and capsule should be 
 opened and the tumour shelled out. When the tumour 
 is pediculated, ligature of the pedicle with removal of the 
 growth should be carried out. If the tumour be extensive, 
 its removal may be difficult owing to its relation to neigh- 
 bouring structures. Sometimes it is only {)ossible to remove 
 part of the mass. 
 
 Carcinoma. -This disease is rare as a primary affection. 
 Out of 4628 cases of primary car' inorna tabulated by Roger 
 Williams, only forty were vaginal, whereas 1571 were uterine 
 (not one being tubal). It may occur as the cauliflower 
 growth, or as any of the other forms. The former generally 
 grows on the posterior vaginal wall ; the other varieties 
 begin in nodules which tend to spread by infiltration. 
 Sometimes the vagina may be completely surrounded by 
 the disease. Ulceration usually occurs over it. When the 
 lower part of the vagina is attacked the inguinal glands 
 enlarge. 
 
 The symptoms are the same as in cancer of the cervix. 
 The early condition must be diagnosed from a hard and 
 soft chancre. 
 
 Treatment.- — If diagnosed early, the mass may be re- 
 moved. When advanced, palliative measures only can be 
 employed. Extirpation of the vagina in bad cases, in which 
 the posterior wall is affected, has recently been advocated 
 by several authorities. Olshausen operates as follows : — 
 
 The perineum is divided obliquely, and the rectum 
 separated from the vagina, the pouch of Douglas being 
 pushed up. As much of the wall as is necessary to remove 
 the growth completely must then be removed. Where the 
 uterus has to be removed as well, the pouch of Douglas is 
 opened. Secondary cancer may spread from the vulva, 
 cervix, or bladder. 
 
 I 
 
 •I 
 
 1 
 
 it 
 
 ! 
 
 i ( 
 
 
 11 
 
 1 
 
V, 
 
 590 AFFECTIONS OF THE VAGINA AND HYMEN 
 
 Sarcoma. This disease is rare. It may "occur at any 
 age, even in childhood. It may be diffuse, soft, and rapidly 
 growing, hard and circumscribed, or melanotic. Spreading to 
 neighbouring parts occurs, rapidly in the case of the first form. 
 
 Treatment. -'V\\{i same as in cancer of the vagina. Eisel- 
 bL'rg reports an interesting case in which the recto-vaginal 
 septum was involved. He resected the coccyx, extirpated 
 the whole disease, and made an artificial anus in the 
 posterior part of the wound. The uterus was pulled down 
 and fastened, so that the wound could be thoroughly closed. 
 
 Tuberculosis of the vagina. — This is more fretjuent than 
 tuberculosis of the vulva. It is usually secondary to tuber- 
 culosis of the upper genital tract, though it may occur 
 independently (Williams). It may be found in the miliary 
 form, or as an ulcer. The latter is irregular in outline ; 
 it is shallow, its base being covered with granulations and 
 caseous matter ; around the ulcer miliary tubercles may be 
 found. The ulcers may perforate bladder or rectum. The 
 disease is generally found on the posterior wall and on 
 the upper third. It is most common between 20 and 40, 
 but may be found earlier and later. 
 
 It may exist when the uterus is not diseased, but when 
 the tubes are affected ; it may be secondary to peritoneal 
 or vesical tuberculosis ; or it may be found with distant 
 tuberculosis. It is possible that tuberculosis may some- 
 times be primary in the vagina or on the vaginal portion of 
 the cervix. 
 
 Treatment. — Tincture of iodine, iodoform, or lactic acid 
 may destroy the disease and lead to healing by healthy 
 granulations. If this will not suffice, the ulcer may be 
 excised and the raw surface closed with sutures. 
 
 Stenosis and Atresia of the Vagina. 
 
 These conditions may be congenital, or they may result 
 from injury. 
 
 \^ 
 
STENOS/S AND AT K ESI A. 
 
 591 
 
 l'"ic;. 226. -—Atresia of the 
 lower end of the vagina. 
 The tubes, uterus, and 
 upper part of the vagina 
 are distended with blood. 
 
 I. Acquired. — In most cases of accjuircd stenosis or 
 atresia, difficult labours account for the condition. The 
 vagina may he torn, and inllam- 
 mation and after-cicatrisation set 
 up, causing stenosis. Parts may 
 slough, owing to compression 
 against the sacrum or the pubes, 
 and this may lead to great con- 
 traction. 
 
 Injury may also be produced 
 in other ways, e.g. by a long -re- 
 tained pessary, and may lead to 
 contraction. It may follow 
 cauterisation. It may result from 
 the use of too hot a douche, caus- 
 ing scalding. It may be due to diseases, e.g. lupus, syphilitic 
 ulceration, cancer, gangrene, phlegmonous vaginitis. It may 
 be due to senile vaginitis. 
 
 The cicatrices may be in any part of the vagina. Those 
 
 resulting from injury in labour 
 are usually situated high up. 
 They may extend completely 
 or partially around the vagina. 
 ^jw/Zf^/w^y. -These vary ac- 
 cording to the degree of the 
 affection. They may develop 
 slowly as cicatrisation ad- 
 vances, and may be retarded 
 
 Fig. 227.-Hymencal atresia, with somewhat if coitus be frequent, 
 distension of the vagina and If Sufficient space be left for 
 uterus by retained menstrual the escape of the menstrual 
 
 flow and for coitus, the patient 
 may notice nothing until the contraction be well advanced. 
 When the passage becomes very narrow there may be painful 
 menstruation or difficult coitus. 
 
 When complete atresia ;..kes place, the menstrual dis- 
 
 1 
 
 w % 
 
59a AFFECTIONS OF THE VAGINA AND HYMEN. 
 
 charge accumulates behind the contraction, and the same 
 
 results follow which I shall 
 describe in connection with 
 congenital atresia. 
 
 In some cases, however, 
 amenorrhrea is brought about 
 (Kennedy). 
 
 Treatment.— \x\ the non- 
 pregnant state, the cicatricial 
 bands may be cut in dif- 
 ferent places ; the vagina 
 
 Fig. 228.— Atresia of the lower part should then be fully packed 
 
 of the vagina. The upper portion ^ -^j^ ^^^ ^ ^^^ ^ 
 
 of the vagina and part of the ° •' ' 
 
 uterus are distended with blood. and, afterwards, glass or 
 
 vulcanite dilators should be 
 
 employed. In some cases where there is a thick cicatrix, 
 
 it may be better to excise it, and to transplant a fresh flap 
 
 of skin. 
 
 2. Congenital. — Various malformations have been de- 
 scribed in connection with those of the 
 uterus. 
 
 Stenosis may exist as an abnormal 
 narrowing of the vagina, along with a 
 normal uterus. It may be due to 
 foetal colpitis, and annular, oblique, or 
 spiral ridges or bands may be formed. 
 Some authorities think that the so-called 
 supplementary hymen arises in this 
 way. But arrested development of the 
 Miillerian ducts may also cause the 
 ccdition. Sometimes one of the Miil- 
 lerian tracts may not have contributed 
 at all to the vagina. 
 
 Atresia may be found in different parts. Most frequently 
 the hymen and lower end of the vagina are affected. 
 
 Sometimes the whole vagina is solid, and may only be 
 
 Fig. 229. — Uterus bi- 
 cornis bicollis, in 
 which there is atresia 
 of the lower portion 
 of the right vagina, 
 the parts above being 
 distended with blood. 
 
 w 
 
STENOSIS AND A TRESIA. 
 
 w% 
 
 represented by a thin fibrous or fibromuscular band. 
 Sometimes a mere diaphragm may exist at some point. 
 
 Complete absence of the vagina, or defectus vagina^ may be 
 considered here also. In this condition there is not a trace 
 of tissue between the rectum and bladder. It is a condition 
 mostly found in monstrosities. According to Ballan- 
 tyne, it is probably always associated with absence of 
 uterus, tubes, external genitals, and with imperfect develop- 
 ment of the mammae. 
 
 Changes resulting from atresia. — These usually do not 
 develop until puberty. When menstruation begins blood 
 accumulates above the atresic portion, and gradual dilata- 
 tion takes place. This may affect the vagina above the 
 hindrance, as well as the uterus and tubes. Hypertrophy 
 of the vaginal wall may occur, but it may become thin and 
 rupture. Rupture of the Fallopian tubes may also occur. 
 The retained blood is at first thick and brown. Later it 
 becomes paler ; fibrin forms on the walls, and blood crystals 
 get deposited. The uterine mucosa may have an eroded 
 appearance ; its glands may be almost entirely destroyed, and 
 inflammatory changes may take place in it. Pus formation 
 may take place. Sometimes the atresic portion may rupture 
 or slough through. Peritonitis may develop about the dis- 
 tended parts. 
 
 I have described an interesting case in which the dilata- 
 tion was most peculiar. The girl had complained of an 
 abdominal swelling and pains for three years. There was 
 an atresia of the lower portion of the vagina, and yet there 
 was no dilatation of the upper portion nor of the uterus. 
 Only the left tube was distended with blood. 
 
 It is generally thought that in atresia cases the distended 
 vagina forms a large part of the retention tumour, and also, 
 as G. Veit has pointed out, that this may develop even be- 
 fore there is any accumulation in the uterus. Usually, also, 
 both tubes are affected, unilateral distension being generally 
 found only where there is atresia of one-half of a double 
 38 
 
 Li !2 
 
594 AFFECTIONS OF THE VAGINA AND HYMEN. '' 
 
 genital tract. The source of the tubal blood in my case 
 was not evident. It was either purely tubal, or purely uLerine 
 menstrual blood, which had been forced upward into the tube, 
 or a mixture of both. In favour of the first hypothesis is the 
 fact that, at the examination of the patient before operation, 
 no distension of the uterus was found — a condition never 
 before recognised in a case where a patient had menstru- 
 ated, and had retained the discharges for one or more 
 years ; against this view is our present knowledge regarding 
 the sources of the blood in menstruation. 
 
 Bandl and a few others believe that, in menstruation, 
 blood is poured from the tubal as well as from the 
 uterine mucosa, and that one of the chief causes of the 
 haematosalpinx in atresia cases is the retention of this tubal 
 flow, owing to some obstruction in the tube lumen. 
 
 All recent observations are opposed to this view. Besides, 
 in my case, the tubal distension was only on one side. 
 No communication could be made out between the dis- 
 tended tube and the uterus. Hennig has pointed out the 
 frequency of closure or contraction of the inner part of the 
 tube in these cases. 
 
 Against the purely uterine origin of the tubal blood is 
 the supposition that reflux of blood from the uterus into the 
 tube could not go on for a long period through the very 
 narrow lumen of the interstitial portion. We know, how- 
 ever, that instrumental pressure can force fluids in this 
 direction, and there is no reason why it should not take 
 place as the result of strong contraction and resistance on 
 the part of the uterus, owing to the way of escape being cut 
 off" from below. 
 
 In this relation should be remembered the tendency of 
 blood in the genital tract to keep fluid. It i? •emarkable, 
 if this explanation be correct, that reflux should take place 
 only into one tube, if the lumen in both were patent. L is 
 probably due to the fact that the resistance was so much 
 greater on one side, for some reason or other, that the flow, 
 
 *> 
 
STENOSIS AND ATRESIA. 
 
 595 
 
 having started by one route, continued so. If the reflux 
 hypothesis as to the origin of the tubal blood be not 
 true, then, either no blood had escaped from the uterine 
 mucosa, or, having done so, reabsorption had soon taken 
 place. 
 
 It is possible that the blood was both tubal and uterine. 
 It is not improbable that, after the tube had been somewhat 
 stretched, as a result of reflux uterine blood, haemorrhage 
 might take place into the tube lumen during the periods of 
 menstrual congestion. Were the latter, however, the sole 
 cause of the condition {i.e. as afiecting the tubes), both sides 
 should have been distended. 
 
 Symptoms. — Sometimes the accumulation of mucus may 
 lead the girl to distinguish a swelling before puberty. 
 Usually, however, no distinct symptoms develop until after 
 puberty. The menstrual periods recur, and there are all 
 the usual signs save escape of blood. Pelvic pain is felt 
 at these times. It increases in duration as the girl grows 
 older, until in many cases it may be continuous. In some 
 cases there is very slight trouble owing to the small quantity 
 of blood produced. There may even be sometimes amen- 
 orrhoea. In other cases the pain may not tend to become 
 continuous, but only to be felt at the menstrual periods. 
 The patient may complain of micturition or defaecation 
 troubles, and of an abdominal swelling, as well as of one 
 at the vulva. 
 
 Physical signs. — On inspection of the external genitals, 
 in case of hymeneal atresia, a bulging may be seen in the 
 position of the introitus vaginae. It may have a bluish 
 tinge, and resemble a bag of membranes. If the lower 
 part of the vagina be atresic, a similar bulging may also 
 be seen, and often the hymen may be made out below 
 it and distinct from it. The urethral orifice is dilated. 
 In atresia high up in the vagina, no bulging is seen at 
 the vulva. 
 
 On abdomino-rectal bimanual examination, the distended 
 
 :|lil^ 
 
596 AFFECTIONS OF THE VAGINA AND HYMEN 
 
 portions may be distinguished. If the atresia be at the 
 hymen, or in the lower third of the vagina, the rest of the 
 canal distended above it is felt as an elastic sac. Some- 
 times, as in the case to which I have alluded, there is no 
 distension of the vagina above the atresia. 
 
 If the case be an early one, the uterus is felt to be 
 hypertrophied above the vaginal swelling. Later, the cervix 
 dilates, and, afterwards, the body. Then one or both of 
 the Fallopian tubes may dilate ; but, as I have shown, tubal 
 distension may occur without uterine or vaginal retention. 
 
 When the vagina is completely atresic, a sound passed 
 into the bladder may be easily felt per rectum. Yet, in a 
 case where there is only atresia of the lower portion, the 
 upper part being normal and undistended, this method of 
 examination may lead to a false diagnosis. When the 
 whole vagina is congenitally wanting, the uterus is usually 
 malformed, though sometimes it is not. 
 
 Treatment. — The condition should be operated upon as 
 soon after puberty as it is discovered ; sometimes before 
 puberty, owmg to the accumulation of mucus, interference 
 may be necessary. 
 
 Just as in cases of atresia of the cervix, the condition 
 of the tubes should be examined. If they are distended, 
 they should be removed first of all. When very slight 
 distension is present, it would be justifiable simply to 
 aspirate the fluid from the tubes, and to close the open- 
 ings, in the hope that they may recover their functional 
 activity. ; - . ; 
 
 If an abdominal section be performed for the treatment 
 of the tubes, the vaginal condition should be attended to 
 after the patient has thoroughly recovered. If, however, it 
 has been found that the whole vagina is wanting, there being 
 no possibility of tunnelling a new slit, nothing can be done 
 after the tubes and uterus are emptied or removed by 
 abdominal section. When the hymen or lower part of 
 the vagina is atresic, an opening should be made in much 
 
 f \ 
 
ATRESIA OF SEPTATE UTERUS AND VAGINA. 597 
 
 the same manner as described in atresia of the cervix {vide 
 p. 436). The hymen may be cut away. 
 
 When the whole vagina is atresic, a new vaginal slit may 
 sometimes be made by tunnelling the recto-vesical septum. 
 This is carried out with bistoury, scissors, and fingers. Care 
 should be taken not to injure bladder, ureters, or rectum. 
 A sound should be held in the bladder by an assistant during 
 the operation. 
 
 The operation is more difficult when there is no accumu- 
 lation of blood above the atresic portion. In such a case 
 the uterus should be pushed downwards through the abdo- 
 minal wall by an assistant, in order tnat the operator may be 
 better able to work his way to the cervix. 
 
 1. 
 
 2. 
 
 Fig. 230. — Vaginal tube, 
 I. Side view. 2. Outer end, showing mode of attaching straps. 
 
 Whenever an atresia is incised, the retained fluid above 
 it is allowed to drain away slowly. The opening is then 
 made as large as possible, and a glass tube introduced. 
 The patient is kept in bed until the freshly-rawed surface 
 granulates and heals. Thereafter she should wear the 
 glass plug for a year or more (except at her menstrual 
 periods), and should understand how to remove it, clean 
 it, and give herself a vaginal douche from time to 
 time. . 'V "■; ■ '.■,"■■.• 
 
 Atresia of one-half of a septate uterus and vagina. — 
 Sometimes the lower end of one-half of a septate vagina 
 may be atresic. This leads to the accumulation of blood 
 
V 
 
 598 AFFECTIONS OF THE VAGINA AND HYMEN 
 
 on this side, forming the condition known as lateral haemato- 
 colpos J if suppuration occur in it, lateral pyocolpos. The 
 corresponding left half of the uterus may be distended — 
 lateral haematometra ; sometimes suppuration may occur in 
 the uterine collection. At times rupture of the vaginal sac 
 may take place into the patent vagina. Pelvic peritonitis 
 or cellulitis may be set up. 
 
 Symptoms. — There may be some accumulation of mucus 
 behind the vaginal atresia before puberty. Usually, how- 
 ever, it is only when menstruation begins that marked 
 symptoms occur. There are pains in the pelvis at mens- 
 truation, and, often, between periods, dysuria and defaeca- 
 tion troubles. There may be a feeling of discomfort due to 
 the swelling in the vagina. 
 
 Menstruation goes on by the open part of th^ tract, but 
 it tends to be irregular. 
 
 Physical signs. — An elastic swelling is found on one side 
 of the vagina. The uterus is enlarged, and distension of 
 one-half niy be made out. Breisky has shown that the 
 lateral haematocolpos may undergo a kind of torsion, the 
 lower end becoming anterior, the upper posterior. 
 
 Differential diagnosis. — When the atresia is low down, 
 the swelling may be mistaken for a vaginal cyst, a hernia, 
 a pelvic hsematoma. When situated high, diagnosis may be 
 very difficult, and the condition may be mistaken for a 
 broad ligament or intraperitoneal swelling close to the 
 uterus. It must also be diagnosed from atresia of half of 
 a septate vagina, where the uterus is bicornuate, or where 
 there is a rudimentary cornu. 
 
 If pregnancy take place in the open half, the difficulty of 
 diagnosis is great, and the condition may easily be mistaken 
 for ectopic gestation. Where there is very great doubt as 
 to the condition of parts, an abdominal exploratory incision 
 may be necessary. Winckel has pointed out that lateral 
 vaginal atresia is also to be distinguished from a condition 
 in which po^'-ets exist on the side of the vagina, due to 
 
SEPTATE VAGINA. 
 
 599 
 
 inversions of the mucosa ; they may be an inch or more in 
 length. 
 
 Treatment — If, with this condition, the Fallopian tube 
 on the corresponding side be at all distended, it should be 
 removed. The atresic vagina should be opened and drained, 
 the septwHi being cut away. The cervix should then be 
 pulled down with a volsella, and the septum in the uterine 
 cavity removed. Afterwards the vagina should be douched 
 daily with an antiseptic lotion. 
 
 Septate vagina. — This is the condition in which fusion of 
 the two Miillerian ducts has not taken place. Very rarely, 
 as in the case of Katherine Kaufmann referred to (p. 541), 
 there may be a double vulva as well. Usually the vulva is 
 single, though the hymen may have two openings. In the 
 majority of cases, the two canals are side by side, one of 
 them, generally the left, tending to lie a little in front. 
 Sometimes the septum is somewhat transverse, so that one 
 canal lies quite in front of the other. Usually one c^nal is 
 a little larger than the other. The septum may ext ,nd 
 throughout the whole vagina; it varies in thickness, and 
 may be perforated at spots. In some cases there may be a 
 mere bond or a ridge on the wall. 
 
 In most cases where the condition is well marked the 
 uterus is septate, bicornuate, or didelphous. The uterus 
 may be single, communicating with only one vaginal canal. 
 It may be unicornuate, the other horn being rudimentary ; 
 in such a case the corresponding vaginal half is rudimentary. 
 
 There may be a single vulva and hymen, and the septum 
 may not reach quite to the latter, but sometimes it may pass 
 into the hymen, which has two openings. The septum is 
 composed of fibromuscular tissue. 
 
 Symptoms. — Sometimes there may be difficulty in coitus, 
 or dyspareunia, but generally the condition is not made out 
 until labour comes on, when it may cause obstruction. 
 
 Treatment. — The septum should be excised. 
 
 Unilateral vagina. — This condition is found, generally, 
 
 
V. 
 
 6oo AFFECTIONS OF THE VAGINA AND HYMEN. 
 
 where there is a unicornuate uterus. The carial is narrowed, 
 and lies somewhat lateral to the mesial plane. 
 
 Abnormal openings into the vagina. — The vagina may 
 communicate with the rectum or urethra. Sometimes it 
 may be septate in this condition. Fordyce has described 
 a septate vagina in an infant where each half opened into 
 the urethra, both canals being atresic at their lower ends. 
 
 Most instances, however, of communication are due to 
 malformation of the vulva, whereby remains of the cloacal 
 stage or of the urogenital sinus condition are left. 
 
 Abnormalities in the structure of the hymen. — The 
 hymen may be very thick and rigid. 
 
 This condition may lead to dyspareunia, or prevent 
 penetration in coitus. Pregnancy, however, may take place. 
 If it exists during labour, it may obstruct the passage of the 
 child. When it does tear, the laceration may be a bad one, 
 and may go deeply into the vulva or perineum. 
 
 Sometimes the hymen is abnormally elastic, and may not 
 tear on coitus or even in labour. In some cases the hymen 
 may be unusually vascular, and may lead to sharp haemor- 
 rhage when torn in coitus. 
 
 Cysts are sometimes found in the hymen. They were 
 first described by Bastelberger, who regarded them as due 
 to an infolding of the surface-epithelium, which became 
 closed in its outer part and afterwards distended. Schauta 
 held a somewhat simhar view. Doderlein and others 
 believe that they are caused by the blending of double 
 hymeneal folds. Ulesko-Stroganowa states that they arise 
 from the obstruction of glands, a mode of origin to which 
 she attributes, also, vaginal cysts -, in reference to this view, 
 however, it is to be said that, normally, no glands are found 
 either in the hymen or vagina, though, as Ruge has demon- 
 strated them on the inner surface of the hymen in a case of 
 atresia hymenalis, it is evident that they may occasionally 
 be found. Klein and von Preuschen have also pointed out 
 their occasional occurrence. 
 
ABNORMALITIES OF HYMEN. 
 
 601 
 
 Palm and others think that these hymeneal cysts are the 
 closed-off ends of a canal (probably the Wolffian duct). 
 There is, however, considerable discussion as to the original 
 position and relationships of the Wolffian duct (^ide p. 67), 
 it being denied by some that it is impossible that Wolffian 
 duct remains should be found as low as the hymen. 
 
 y 
 
 I. 
 
 i 
 
V 
 
 CHAPTER XXL, 
 
 AFFECTIONS OF THE URETHRA AND 
 BLADDER. 
 
 Urethra. 
 
 Developmental Defects. — Absence of the whole 
 urethra sometimes occurs. This may be found with or 
 without other malformations. The bladder may open by 
 a slit into the lower part of the vagina in such cases. Some- 
 times only the inner portion may be wanting ; sometimes, 
 the outer ; sometimes, the middle portion. 
 
 Epispadias, or defect of the upper wall of the urethra, 
 may be found without any corresponding affection in the 
 bladder, but usually this viscus is also involved. The 
 whole or outer part of the urethra is found as an open 
 groove. On each side lies one-half of the split clitoris 
 with its corresponding labium minus. The labia majora 
 may be joined normally in the anterior commissure, or 
 may be divergent. The bladder is complete, and usually 
 the symphysis is closed. There may be a scanty growth 
 of hair on the mons veneris. The bladder is generally 
 smaller than normal. 
 
 Symptoms. — Incontinence of urine is the chief feature. 
 This may be continual, but usually it is only marked 
 when sudden movements are made. The genitals become 
 tender and excoriated. Menstruation usually continues, 
 however, and pregnancy may take place. 
 
 Treatment. — A plasllc operation should be performed 
 
DEVELOPMENTAL DEFECTS. 
 
 603 
 
 for the purpose of closing in the deficiency. If this fail, a 
 urinal requires to be worn continually. 
 
 Hypospadias occasionally occurs. This may be found 
 as a mere deficiency of the posterior wall of the urethra ; 
 more commonly it exists as part of the condition known as 
 persistence of the urogenital sinus. 
 
 Dilatation of the urethra. — This condition may affect the 
 whole or the outer part of the urethra. It may be caused 
 by coitus where the vagina is defective, or it may be brought 
 about by means of a tumour. 
 
 Treatment. — Longitudinal furrows may be burned along 
 the dilated portion. If this is not sufficient, a plastic opera- 
 tion may be tried, a portion of the posterior wall being cut 
 out and the raw edges brought together. 
 
 Stricture or stenosis of the urethra. — This may result 
 from cicatrisation, after bad labours or from the presence 
 of a new growth. It may gradually form in a vesico-vaginal 
 fistula. Sometimes it follows gonorrhoea. It may also 
 develop after operations on the urethra. 
 
 Treatment. — If no tumour exists, gradual dilatation with 
 bougies is to be carried out. Sometimes it is necessary as 
 well to cut the cicatrix from without. 
 
 Displacement. — The whole urethra may be altered in 
 position, following displacements of the bladder. 
 
 Urethritis. — Inflammation in the urethra is generally due 
 to gonorrhoea. It may follow the use of dirty instruments, 
 injuries, the irritation of a new growth, masturbation, awk- 
 ward coitus. 
 
 The mucosa swells, becomes congested, and a catarrhal 
 discharge is produced. 
 
 When acute gonorrhoeal infection is the cause there is 
 usually first an itchiness about the urethra, then a prickling, 
 burning pain ; frequency of micturition and dysuria ; in 
 three or four days a sticky secretion oozes out, and then an 
 abundant purulent discharge. In about twenty days this 
 begins to decrease, and it may entirely disappear in thirty 
 
V. 
 
 Fig. 231. — Pus Irom urethra, stained 
 to show gonococci. 
 
 604 AFFECTIONS OF THE URETHRA AND BLADDER, 
 
 or forty days. Sometimes there may be blood in the dis- 
 charge. Catarrh of the bladder may also be present. 
 Skene's glands, and those around the meatus, may remain 
 
 affected for a I0115 time. 
 Prolapse of the mucosa may 
 take place. 
 
 Treatment. — Vide 
 " Acute Vulvitis," p. 545. 
 
 Urethrocele. — This is a 
 dilatation of the posterior 
 urethral wall. It forms a 
 swelling on the anterior 
 vaginal wall. Inflammation 
 may occur in it, and deposit 
 of lime salts take place. 
 Possibly, in some cases, 
 the neck may become closed, so that a cyst is left in the 
 anterior vaginal wall. 
 
 The cyst may become as large as an egg. This condition 
 may cause a feeling of dis- 
 comfort, as of something 
 pressing down; there may 
 be dysuria ; sometimes there 
 is incontinence when sud- 
 den movements are made ; 
 dyspareunia may be present. 
 Treatment. — The anterior 
 vaginal wall should be in- 
 cised, the cyst removed, and 
 the opening closed with 
 continuous catgut suture. In 
 some cases it may be well 
 to drain the bladder by a lead catheter for two or three 
 days after the operation. 
 
 Retention cysts are sometimes found. near thje meatus; they 
 are probably due to closure of the outer ends of Skene's glands. 
 
 
 Fig. 232. — Section of part 01 urethral 
 wall in acute gonorrhcea. The 
 epithelium is considerably shed. 
 
DE VEL OPMENTAL DEFEC TS. 
 
 tes 
 
 FiBBure of the urethra. — This condition is sometimes 
 found at the inner end of the urethra. It is a very trouble- 
 some condition, and may cause much discomfort and pain, 
 especially in connection with micturition. 
 
 Treatment. — At first, dilatation of the urethra should be 
 tried. The function of the sphincter is destroyed for a 
 time, and, during this period of rest, the fissure, which has 
 been stretched, has a chance to heal. Along with the 
 dilatation the application of the cautery to the fissure by 
 means of an endoscope is made by some operators. If 
 these methods fail, the establish- 
 ment of a vesico-vaginal fistula 
 for a time may be necessary. 
 
 New Growths. — Angioma or 
 urethral caruncle is important. 
 It may vary in size from a pea to 
 a hazel-nut, and forms a deep red 
 mass at the urethral orifice. It 
 may be somewhat pedunculated, 
 and bleed easily. Usually only 
 one exists ; sometimes two or 
 three. It consists of dilated capil- 
 laries; blood is often diffused 
 among the connective tissue ; it 
 is rich in sensory nerves. 
 
 It causes pain on coitus and dysuria ; sometimes, reten- 
 tion. It bleeds on being irritated. 
 
 Treatment. — It should be thoroughly burned off with a 
 cautery at a dull red heat. If there should be much after- 
 bleeding, a plug of gauze held against the spot by a perineal 
 band acts as a haemostatic. Fibroma sometimes grows in 
 the wall of the urethra. It may be polypoidal in the canal. 
 Myxoadenoma, sarcoma, carcinoma, and other growths may 
 be found. 
 
 Prolapse of the urethra. — Kleinwachter describes two 
 varieties, one in which the mucosa near the meatus is 
 
 Fig. 233. — Section through 
 portion of urethral car- 
 uncle. Large blood- 
 spaces are shown. 
 
V. 
 
 6o6 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 everted, the other in which it becomes loosened higher up, 
 gradually extending down until it appears at the meatus. 
 A. R. Simpson has described two interesting cases of the 
 former condition ; in one of these it developed suddenly, 
 following a fall ; in the other, it was caused by the dragging 
 down of a caruncle as large as a cherry. Inflammatory 
 changes may take place, and erosion or ulceration or 
 gangrene be caused. The prolapsed mucosa ^ay in old 
 cases sometimes take on a skin-like character. 
 
 I examined Professor Simpson's cases microscopically, and 
 found that in both cases the epithelium covering the prolapse 
 was transitional, like that in the upper end of the bladder. 
 Cross-sections resembled the structure of a caruncle, i:.d 
 in the second specimen it was impossible to say where the 
 caruncle began and the prolapse ended. It is, indeed, 
 possible that a caruncle may begin as a localised prolapse. 
 
 The symptoms vary. Sometimes there is no discomfort. 
 In other cases they are the same as in caruncle. Sometimes 
 the patient only complains of the bleeding which is found. 
 
 Treatment. — The prolapsed portion may be cut ofl", and 
 the edge sutured to the margin of the urethra. 
 
 In the case of prolapse of the upper portion of the 
 mucosa, it may be necessary to split open the urethra in 
 order to remove the redundant portion. 
 
 Bladder. 
 
 Malformations. — Epispadias (ectopia vesicae, extrover- 
 sion of the bladder) is rare in the female. In the most 
 common variety, there is a failure in development of the 
 anterior wall of the bladder, and of the anterior abdominal 
 wall in front of it. There is also a deficiency in the pubic 
 arch in the majority of cases. y 
 
 The posterior bladder wall appears as a red surface, which 
 bleeds easily. The openings of the ureters may be seen, 
 from which urine escapes in small irregular jets. Here and 
 
MALFORMATIONS OF BLADDER. 
 
 607 
 
 there the mucosa has epidermic characters ; at the edge of 
 the red area the mucosa joins the skin. The skin is marked 
 by cicatrices, supposed to be remains of the allantois. The 
 ectopion may reach up to the umbilicus. 
 
 The labia and halves of the clitoris are separated. The 
 vagina and uterus are occasionally double. The sacrum 
 usually projects well forward. The ureters bend down into 
 the pelvis before passing up towards the kidneys. They 
 may be elongated and distended. 
 
 There is a rarer condition of ectopion in which the 
 whole cloaca opens anteriorly, the bladder not having been 
 developed to any extent. Variations may be found between 
 this and the first-mentioned form. 
 
 Symptoirr. — Usually the patient is run down in health. 
 There is constant dribbling of urine, and much local discom- 
 fort. Excoriation, inflammation, ulceration may develop on 
 the vesical mucosa or skin ; the ureters may become affected, 
 and the kidneys get diseased. Sexual appetite is usually ab- 
 sent, though pregnancy may occur. Menstruation is irregular. 
 
 Treatment. — Previous to any attempt at operative treat- 
 ment, the health of the patient should be made as good, 
 and the local conditions as favourable as possible. If the 
 urethra be deficient, it should first of all be restored by a 
 plastic operation. 
 
 Afterwards, the malformation in the lower abdominal 
 region is closed. If there be a mere fissure, the edges 
 should be pared and stitched together. If there be con- 
 siderable deficiency in the anterior abdominal wall, a plastic 
 operation should be undertaken. 
 
 Flaps are made from adjacent parts of the abdominal 
 parietes and turned inwards over the opening, their edges 
 being stitched together and to the pared edges of the 
 opening. In this way the skin surface forms the new 
 anterior wall of the bladder. The flaps may be taken from 
 above and from each side of the opening, or one large one 
 may be taken from an inguinal region. 
 
V. 
 
 6o8 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 Some prefer, after making the flaps, to cover the raw 
 surface with skin grafts. Afterwards, at a second operation, 
 the edges of the flaps and of the opening are brought 
 together. If the skin-grafting is not undertaken, it is necessary 
 to dress the raw surface carefully with iodoform collodion. If 
 these attempts fail, an artificial urinal should be worn. 
 
 Doable bladder. — Two bladders are very rarely found 
 (^ide p. 541). Sometimes the single bladder has a median 
 partition, large or small. Or it may be found with saccula- 
 tions. 
 
 Absence of the bladder is sometimes met with. The 
 ureters may open, in such a case, into urethra, rectum, or 
 vagina, or through the abdominal wall. 
 
 Cyst of the urachus is sometimes found, communicating 
 with the bladder. Sometimes the urachus is patent, and 
 communicates with the exterior at the umbilicus. ■> 
 
 Displacements. — The bladder may be displaced in various 
 ways by tumours. It may be dragged downwards by pro- 
 lapsus uteri or by supravaginal hypertrophic elongation of 
 the cervix; in cystocele; by old cellulitic or peritonitic 
 cicatrisations. It may form a hernia into the inguinal, 
 femoral, obturator, or sciatic foramen ; sometimes it may 
 bulge into the abdominal wall at the scar of an old 
 laparotomy incision or of a healed abscess, or if the 
 muscles be weak or separated in the middle line. 
 
 Where the bladder becomes herniated, it tends to become 
 sacculated; urine may collect in the protruding part, de- 
 composition set up, and calculus, perhaps, formed. The 
 bladder is also somewhat displaced in labour. 
 
 Prolapse of the vesical mucosa through the urethra is 
 a very rare occurrence. It is stated by some that the whole 
 bladder wall may thus prolapse — inversio vesicae. 
 
 Cystocele. — This condition has been considered under 
 " Downward Displacements of the Pelvic Floor " {vide 
 p. 5 7 1 ). It is not uncommon in fat multiparae with pend- 
 ulous belly, and in women after the menopause. 
 
 \t\ 
 
INFLAMMATION IN THE BLADDER. 
 
 ^ 
 
 Inflammation in the bladder. — Pathology. — Cystitis may 
 be acute or chronic. In most cases, the inflammation 
 begins in the mucosa, and is mainly limited to it, though, 
 sometimes, the wall may be infected from the outer surface. 
 
 In acute cases there is congestion of the mucosa, pro- 
 liferation, cloudy swelling, and shedding of the epithelium, 
 while leucocytes and serum are poured out of the dilated 
 capillaries. Inflammatory products may also be found in 
 the neighbouring part of 'he wall. This condition may 
 become chronic, may get well, or may give rise to abscesses 
 in the wall, ulcers, or a gangrenous condition. Sometimes 
 a croupous membrane forms. 
 
 When the latter takes place, exfoliation of a large area of 
 the mucosa or even of the muscular part of the wall as well 
 may result. 
 
 In chronic cases the mucosa is generally of a greyish 
 colour, irregularly mottled in parts, and covered with a layer 
 of pus. It is increased in thickness ; the covering epithelium 
 is considerably altered from the normal and exfoliated ; 
 ulcerations may be present ; the wall outside the mucosa is 
 somewhat hypertrophied, owing to infiltration with inflam- 
 matory products, so that its capability of expansion may be 
 greatly diminished. In some cases a croupous false mem- 
 brane forms on the surface, composed of fibrinous material, 
 or, sometimes, of proliferated epithelium. It may extend 
 up the ureters to the kidneys sometimes. Rarely viL^as 
 projections may form on the wall — the so-called "villous 
 cystitis." In many cases phosphatic deposits are found on 
 the wall. 
 
 Etiology. — It is extremely likely that the active factor 
 in causing cystitis is micro-organismal. The microbes may 
 enter by way of the urethra, with or without inflammatory 
 changes in the urethra, e.g. gonorrhoea. They are often 
 introduced by the use of dirty instruments in catheterising 
 and in performing operations. 
 
 Various microbes may set up cystitis, one of the most 
 39 
 
 
 I ! 
 
V 
 
 6io AFFECTIONS OF THE URETHRA AND BLADDER, 
 
 common being the Bacterium co'li commune. Staphylococci 
 are often the cause, being usually the agents in puerperal 
 cases. In infection from gonorrhoea the gonococcus is rarely 
 found in the bladder, staphylococci probably being the 
 important attacking agents. The different germs causing 
 suppuration may also be found as well as other varieties. 
 
 Various conditions tend to depress the vitality of the wall 
 and to favour infection, e.g. pressure of the foetal head in 
 labour, of a tumour, or of a vaginal pessary ; chronic con- 
 gestion in the pelvis, as in metritis ; inflammation outside 
 the bladder; downward and backward displacements of 
 the uterus, especially in early pregnancy ; foreign body 
 in the bladder; over-distension of the bladder; cold, ex- 
 cessive coitus, poor health, rheumatism, gout, tubercle, 
 certain drugs, e.g. cantharides, excess of balsams, quinine, 
 iodides. 
 
 Symptoms and physical signs. — In acute cases there is 
 painful and frequent micturition. There is a feeling of 
 weight and fulness in the pelvis, and if the patient try to 
 retain urine, sharp darting pains occur in the region of the 
 anus. Rectal tenesmus is often found, occurring at inter- 
 vals. After emptying the bladder, pain may continue for 
 a time. Examination by the vagina or rectum causes pain ; 
 also the introduction of a sound into the bladder. There is 
 often no rise in temperature ; if this takes place, it may point 
 to «n extension of the inflammation up the ureters or outside 
 the bladder wall. The urine is diminished, highly acid, 
 and contains epithelial cells, blood, pus, mucus, urates, uric 
 acid, etc. Only slight traces of blood are usually found. 
 When the pus is uniformly diffused through the urine, 
 there is probably an extensive affection of the mucosa ; 
 when the first and last portions of the urine contain it most 
 abundantly, the neck and base are probably affected. 
 
 In chronic cases the symptoms may begin gradually or 
 may follow an acute attack. The symptoms are those 
 already described, only modified. In old cases the patient 
 
 W 
 
INFLAMMATION IN THE BLADDER. 
 
 6ii 
 
 gets thin and worn, and the 'whole system runs down. There 
 may be pain on coitus; and rises intemjjerature. 
 
 The urine contains mucus and pus in various quantities ; 
 it is alkahne, and has a somewhat strong unpleasant smell, 
 decomposition being easily set up in it. On bimanual exam- 
 ination some pain is caused when the bladder is pressed 
 between the fingers. It may be felt to be thickened. 
 
 Cystitis must be diagnosed from tuberculosis of bladder 
 or kidney, pyelonephritis, neuropathic vesical conditions, 
 cystocele, pressure of tumours, and other swellings outside 
 the bladder which cause frequency of micturition, vesical 
 tumours, calculus. 
 
 In all doubtful cases the interior of the bladder should 
 be carefully examined by the Kelly method, and, if neces- 
 sary, urine should be drawn from the ureters, so that the 
 discharge from each kidney may be examined {vide p. 185). 
 
 Treatment. — If any favouring condition exist, it should 
 be attended to. I n acute cases the patient should be placed 
 in bed, the bowels kept open, and a diet of milk and 
 diluent drinks administered. A mixture containing liquor 
 potassoe, hyoscyamus, and buchu should be given internally. 
 Sometimes morphine suppositories must be used on account 
 of the pain. Hot hip-baths are often beneficial. 
 
 In the most severe cases some authorities recommend 
 dilatation of the urethra, or making an .)pening into the 
 bladder through the anterior vaginal wall, in order to give 
 the viscus thorough rest. 
 
 In chronic cases, the bowels should be carefully regulated ; 
 milk diet and diluent drinks should be given, alcohol being 
 avoided. Inwardly, salol, ammonium benzoate. or boracic 
 acid may be given. 
 
 In obstinate cases of this condition, when the ordinary 
 medical treatment is insufiicient, continual drainage of the 
 bladder may be tried. This should be done by means of 
 the urethra, which must be dilated with Hegar's dilators. 
 The action of the muscles which compress the urethra is 
 
 ril 
 
 i 
 
V. 
 
 6i2 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 interfered with for a time. If the muscles rc'~ain their 
 power too soon, anotlier dilatation should be per(. med. 
 
 The patient remains in bed. During the day she may 
 rest against an inclined plane, so that the back is somewhat 
 elevated. Twice daily a weak antiseptic douche is given, 
 e.i:^. boracic ; iodoform bougies should be i)assed into 
 the bladder cavity. If too much dilatation be made, per- 
 manent paralysis of the urethra may remain. A diameter 
 of 20 mm. is the usual limit in an adult. When drainage 
 by the urethra fails to cure the case, an artificial opening 
 should be made through the anterior vaginal wall. The 
 patient is pip* ed in the lithotomy position. The cervix 
 is pulled down, and the anterior vaginal wall held steady 
 with volselhv;. 
 
 A sound is passed into the bladder, the i)oint being made 
 to press the base forwards just above the inner end of the 
 urethra. A mesial incision is then made through the 
 anterior vaginal wall and the base of the bladder, the knife 
 cutting on the point of the sound. With a pair of scissors 
 this incision is lengthened upwards for about three-quarters 
 of an inch. A finger is introduced to feel the condition of 
 the bladder wall. If any crystals of lime are attached to 
 the wall, they should be removed. The bladder is next 
 washed out. Then, with small full-curved needles and 
 catgut sutures (No. 2), the vesical and mucosal edges of 
 the wound are united all around the oi)ening. The patient 
 remains in bed, daily vaginal antiseptic douches being given. 
 
 When the patient is cured, the fistula is closed, according 
 to the method described on p. 626. 
 
 Tuberculosis of the bladder. — This disease may be found 
 at all times of life ; it is more common in women than in 
 men. Very rarely is it limited only to the bladder ; there 
 is usually tuberculosis elsewhere in the body. Miliary 
 tubercles develop in the mucosa, and in advanced stages 
 ulceration takes place, either as several small ulcers or as 
 a large one. The disease may extend down the urethra or 
 
 i\ 
 
NECKOS/S OF THE /if. ADDER. 
 
 61.3 
 
 perforate the vagina and rectum. It may lead to an abscess 
 outside the wall, which may burrow and ()[)en '\n different 
 directions. It tends gradually to shrink up behind the 
 symphysis. The walls may become sclerosed, and the 
 muscle atrophied, so that the viscus loses its power of 
 contracting and expanding. The disease may spread to 
 the ureters and kidneys. 
 
 The early symptoms arc fretpiency of micturition after 
 meals and at night ; afterwards, in the daytime as well. 
 Slight traces of blood appear in the urine. I'ain gradually 
 develoi)s, and pus is produced. All the conditions of 
 chronic cystitis are then found. Sometimes there may be 
 reflex spasms of the walls of the urethra, causing retention. 
 Where ulceration destroys the neck of the bladder to a con- 
 siderable extent, there may be incontinence. The pain 
 varies greatly ; it is sometimes slight, but usually severe, 
 being felt in micturition or continuously. Sounds should 
 not be i)assed for diagnosis in this disease because of the 
 danger of injuring the wall. The urine usually contains 
 tubercle bacilli, but these may not be found if there be 
 much pus. 
 
 The general treatment is the same as for tulx-rculosis 
 elsewhere. Articles of diet and drugs which irritate the 
 bladder should be avoided, ^..v. alcohol, spices, cantharides, 
 nux vomica, etc. Morphine may be often necessary. Local 
 treatment often consists in washing out the bladder with 
 I in 8000 to I in 10,000 corrosive sublimate lotion, or with a 
 solution of formalin (i in 4000). 
 
 As a last resort, suprapubic cystotomy may be tried, in 
 order to apply antiseptics to the bladder. 
 
 Necrosis of the bladder. — This condition has been chiefly 
 studied by Haultain in recent years. He thinks that it may 
 be brought about by traumatism, local poisons, and inter- 
 ference with the circulation. Thus, it may be found as a 
 result of retroflexion of the gravid uterus, the pressure of 
 the foetus in a delayed labour, distension of the bladder. 
 
 
 1! 
 
 i« 
 
V 
 
 6 14 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 cystitis, etc. It is extremely probable that in most cases 
 the action of microbes is an important factor. 
 
 The mucosa alone may be affected, or the mucosa and sub- 
 mucosa ; sometimes these along with the muscular coat, or, 
 indeed, the whole thickness of the wall. The wall may be 
 perforated ; exfoliation of the dead tissue may occur, and 
 this may be followed by the opening. 
 
 Clinical features. — They differ considerably. The tem- 
 perature varies in different cases ; it is always raised when 
 exfoliation takes place. Retention and incontinence of 
 urine are often found. The urine contains much debris 
 and is usually ammoniacal. The exfoliated portion may 
 protrude as a non-vascular, foul-smelling mass. It may be 
 mistaken for an inversion of the bladder, which has not, 
 however, these characteristics. \ 
 
 Treatment. — When exfoliation is taking place, the urine 
 should be drawn off and the bladder washed out every few 
 hours with a strong antiseptic. Tf there is a tendency to 
 retention of urine, it is ". est to make an opening into the 
 bladder through the anterior vaginal wall. 
 
 Calculus in the bladder. — This condition is rarer in 
 women than in men (5 to 100, according to Auvard). The 
 causes of stone are not so often met with in women, and, 
 owing to the shortness and dilatability of the urethra, small 
 calculi may easily be passed from the bladder. 
 
 Etiology. — A stone may pass from the kidney, and in- 
 crease in the bladder. Cystitis and decomposition of 
 urine may give rise to it. It may develop in connection 
 with foreign bodies or tumours in the bladder, in con- 
 ditions where a cul de sac may form in which urine may 
 gather and decompose, e.g. sacculated and herniated bladder, 
 prolapsus. 
 
 Pathology. — There may be only one or many, and great 
 variations in size are found. They are of different shapes ; 
 when several exist together, they are usually faceted. The 
 surface is smooth, granular, or rough. 
 
 rv 
 
CALCULUS IN THE BLADDER. 
 
 Oxalate of calcium usually forms in rounded, nodulated, 
 slate-coloured masses. 
 
 Calculi of uric acid and ammonium urate are ovoid and 
 somewhat flattened, with a smooth or granulated surface ; 
 the uric acid masses being yellow. Phosphatic calculi are 
 irregular in shape, as a rule, and of a grey-white colour. 
 Mixed forms may be found. 
 
 Symptoms. — Pain is often found. It may be constant in 
 some cases ; probably, where there is cystitis. Generally 
 the pain is felt after jumping, walking, driving, riding, etc. 
 It is usually eased when the patient lies down. Where the 
 stone is of some size, there may be much pain in the 
 bladder, urethra, perineum, loins, groins, or in the legs, owing 
 to the contraction of the bladder on it. There is frequency 
 of micturition ; sometimes the flow is stopped suddenly. 
 Hsematuria is an important symptom ; it usually occurs 
 after much exertion, or after driving, riding, etc. 
 
 In some cases of small stone there may be no symptoms, 
 or very slight ones. Sometimes they may be passed per 
 urethram spontaneously. 
 
 Physical signs. — On bimanual examination it may be 
 possible to feel the mass or masses in the bladder. With 
 a sound they may be felt when the instrument is introduced 
 into the viscus. 
 
 Treatment. — Small stones may be removed through a 
 dilated urethra by means of a pair of slender forceps. If 
 necessary, a tubular speculum may be used. 
 
 A stone of moderate size may be crushed in the ordinary 
 manner, the debris being washed out. 
 
 If there be much cystitis, or if the stone be too large or 
 too hard to allow of crushing, it must be removed by an 
 opening through the anterior vaginal wall or by suprapubic 
 cystotomy. The former method is to be chosen, save when 
 it is not possible to adopt it. The patient is placed in the 
 ; lithotomy position, the vagina well exposed with specula, 
 the cervix pulled down, and the anterior vaginal wall fixed. 
 
V 
 
 6i6 AFFECTIONS OF THE URETHRA AND BLADDER, 
 
 t 
 
 If necessary, a sound is passed into the bladder as a guide to 
 the knife. 'I'he incision is made in the middle line as long as 
 is necessary. The stone is then removed en masse. It may 
 be crushed if it is too large to extract otherwise. The 
 interior of the bladder should be carefully washed out, 
 and then explored with the finger. If there be little or no 
 cystitis, the wound should be closed with catgut sutures 
 (No. 2 or 3), as in the case of repair of a vesico-vaginal 
 fistula {vide p. 627). The after-treatment is the same as in 
 the case of a fistula repair. 
 
 If marked cystitis be present, it may be necessary to close 
 only the up[)er part of the wound, leaving the lower part 
 open to act as a drain for a few weeks. When the patient 
 has recovered, complete closure can be carried out. 
 
 Neoplasms of the bladder. — New growths are most fre- 
 quently found in the region of the trigone, next on the 
 posterior wall, then at the neck, and, finally, on the anterior 
 and lateral walls (Auvard). The benign tumours are usually 
 rounded and localised, the malignant more difiused. 
 
 Carcinoma may be found in its various forms. It is 
 usually secondary to rectal, vaginal, or uterine cancer ; it 
 may, however, be primary. It may grow from a single 
 nodule, or several nodules may fuse ; it tends to infiltrate 
 widely, and ulceration occurs in the mucosa over it. As a 
 rule, cancer of the bladder grows slowly. 
 
 Sarcoma is rare. 
 
 Myoma, fibroma, fibromyxoma are sometimes found ; the 
 latter are pedunculated. 
 
 Adenomata or mucous polypi sometimes develop from 
 the vesical mucosa, and may grow down through the urethra 
 or distend the bladder. 
 
 Papilloma is found either as a stalk with long villous projec- 
 tions, composed of delicate, vascv.lar connective tissue stroma, 
 covered with epithelium, or as a sessile or pedunculated 
 warty growth of firm consistence ; the latter may be single or 
 multiple, and varies in size from a pin's head to a walnut. 
 
 -f^ 
 
NEOPLASMS OF THE BLADDER. 
 
 617 
 
 Angioma, dermoid cyst, and simple cyst may sometimes 
 be found in the wall. 
 
 Bilhaxzia hssmatobia in the tropics sometimes leads to 
 the formation of fungating masses in the bladder. 
 
 The following changes may be found as a result of new 
 growths in the bladder: — Deposit of salts on the growth, 
 formation of calculus, cystitis, hydronei)hrosis, nephritis, 
 pyelonephrosis, hypertrophy of bladder wall. 
 
 Symptoms. — In some cases of benign tumour, there may 
 be no symptoms. Usually, however, hiematuria, pain, and 
 micturition troubles are present, though varying greatly in 
 their severity in different cases. The most important of 
 these is haimaturia. It may appear at any time in small 
 or large quantity, and is not related to strains or jolts. It 
 may last for hours, days, or weeks, and then suddenly 
 disappear. The l)lood is more marked at the end of 
 micturition usually. In cases where the blood loss is 
 slight, the patient may notice the darkening of the urine, 
 most marked in the morning. Where the blood loss is 
 great, clots may form. 
 
 The patient may become very anoemic and cachectic- 
 looking, even when the tumour is benign, and the legs may 
 become oedematous. Pain usually appears late, and is 
 mostly due to cystitis ; but it may be caused by the infiltra- 
 tion and extension of malignant disease. Micturition is 
 frequent, and in some cases painful. The flow may be 
 stopped by a clot or by a piece of the tumour ; sometimes 
 there is much difficulty in emptying the bladder. 
 
 Physical signs. — Sometimes a small tumour may be seen 
 projecting out of the urethra. On bimanual examination, 
 especially under an anaesthetic, the neoplasm may sometimes 
 be distinctly felt. When small or soft it may be missed in 
 this way. On examination of the interior by the Kelly 
 method, the growth may be seen. On dilating the urethra, 
 it ma^' be felt with the exploring finger. 
 
 A valuable aid in diagnosing the source of blood is dis- 
 
 
6i8 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 tension of the bladder with aseptic water ; if, on expulsion, 
 the fluid be followed by luemorrhage, the vesical origin of 
 the blood is indicated. Sometimes, where the neck of the 
 bladder is affected, blood flows through the catheter as it is 
 introduced or removed. 
 
 Treatment. — The treatment depends on the size and 
 situation of the tumour. Sometimes small pediculated 
 growths may be twisted off through the dilated urethra. 
 
 larger growths may be removed by means of a vertical 
 mesial incision through the anterior vaginal wall and base 
 of the bladder. The tumour should be removed with the 
 cautery at a dull red heat. The opening into the base may 
 then be closed. For large growths the operation of supra- 
 pubic cystotomy may be employed. This operation is 
 performed as follows : — The patient is prepared as for an 
 abdominal section. She is placed in the dorsal or Tren- 
 delenburg position. Some operators distend the bladder 
 or rectum with air or warm sterilised water (99" F.) in 
 order to push up the peritoneum as much as possible. 
 Others think this unnecessary. It may be dangerous to 
 distend the bladder when there is disease in its wall. If 
 it be not distended, it should at least be filled. 
 
 A vertical mesial incision 2 or 3 in. in length is made 
 through the skin and superficial fascia immediately above 
 the symphysis. It is then carried transversely across the 
 top of the pubes. The origins of the recti and pyrami- 
 dales muscles are divided a short distance above the bone. 
 The thumb and finger are passed behind the symphysis, 
 the peritoneum being separated somewhat from the bone 
 if it be attached, and the extraperitoneal tissues in the 
 region of the apex of the bladder drawn upwards. 
 
 A loop of silk-worm gut or of silk is now passed through 
 the thickness of the muscular wall at the lowest part of 
 the bladder which can be reached behind the symphysis. 
 Another is passed higher up just below the attachment of 
 the peritoneal reflection. The wall of the bladder is divided 
 
 |\ 
 
FOREIGN BODIES IN THE HI. ADDER. 
 
 619 
 
 vertically between these fixation loops until the vesical 
 mucosa is seen as a bluish membrane. All bleeding; is 
 checked, and the mucosa is incised with a bistoury. 'I'he 
 finger is (juickly introduced to prevent escape of the con- 
 tained fluid, and the bladder is explored, 'i'he opening 
 may be enlarged according to the recjuirements of the case. 
 Sometimes it may be necessary to resect a triangular 
 portion of the symphysis subperiosteally, in order to obtain 
 room. The base of the triangle is the upper margin of the 
 symphysis. 
 
 After the operation is finished, the bladder wall is closed 
 by two rows of catgut sutures. One of these secures the 
 mucosa, the other the muscular coat and the overlying 
 cellular tissue. The divided ends of the recti and pyramidales 
 are brought together and the outer wound closed, save at 
 the lower end, where an iodoform-gauze drain is placed in 
 the wound. 
 
 After-treatment. — Practically the same as after a vesico- 
 vaginal fistula repair. In addition the abdominal vvound 
 must be cared for. 
 
 When the tumour cannot be removed, it is sometimes 
 advisable to remove as much as possible, the raw surface 
 being cauterised. In such cases it may be necessary to 
 establish a permanent fistula either by the vagina or by the 
 abdominal wall. 
 
 Foreign bodies in the bladder. — Various articles may be 
 introduced, e.^. hairpins, buttons, etc. They may ulcerate 
 through the wall, e.g. a pessary from the vagina ; worms, 
 faeces, and other bodies from the bowel ; portions of a 
 fcetus from an ectopic gestation sac ; contents of abscesses 
 and cysts. They tend to set up cystitis, and may work 
 their way through the wall, attended by suppuration. They 
 may become the nucleus of calculi. 
 
 Treatment. — They are to be removed according to the 
 principles observed in the removal of stone. (.Complications 
 require attention. 
 
V 
 
 620 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 Rupture of the bladder. — This may be caused sometimes 
 by violent straining, made by a patient when the bladder is 
 distended, or from some injury, e.^. a kick in the abdomen. 
 Generally, the rupture is intraperitoneal, though it may 
 be extraperitoneal ; sometimes both varieties are found in 
 the same tear. Very rarely may rupture take place spon- 
 taneously, as a result of over-distension, e.g. in retroversi ' » 
 of the gravid uterus, and various weak conditions of the 
 bladder wall. Sometimes rupture may be due to ulceration, 
 or to sloughing, following inflammation or pressure. 
 
 The most common site of rupture is the posterior wall. 
 Urine is poured into the peritoneal cavity, when the rupture 
 is intraperitoneal. Peritonitis may or may not quickly fol- 
 low, depending on the presence of micro-organisms. When 
 the urine is extraperitoneal it becomes extravasated. 
 
 In diagnosis it may be of service to inject a warm aseptic 
 lotion into the bladder ; if the viscus be all right, it en- 
 larges, and the fluid can again be drawn off through the 
 catheter. 
 
 Treatment. — The condition of shock which is present 
 must be attended to. If the rupture be into the peritoneum, 
 abdominal section should be carried out, the rupture sutured, 
 and the bladder drained by the urethra for days. If it is 
 necessary to wait for a time before this operation can be 
 carried out, the bladder should be drained per urethram, 
 until abdominal section can be carried out. In extra- 
 peritoneal rupture it may be sufficient to carry out contin- 
 uous drainage of the bladder by way of the urethra. 
 
 I 
 
 Ureters. 
 
 Anomalies. — The ureter may be double on one or both 
 sides. Those of one side sometimes cross in their course. 
 Occasionally a larger number have been reported. It may 
 sometimes open into the rectum, vagina, or urethra ; though 
 in such cases the bladder may be absent. It has been 
 
 ■i\-- 
 
GENITO-UKINARY FISTULA. 
 
 62 ( 
 
 Stated that it may sometimes open at the side of the hymen, 
 or in the mons veneris. • > • ' 
 
 « \ 
 
 Genito-Ukinary Fistula. 
 
 The following fistulte may be formed between the urinary 
 and genital passages : — Urethro-vaginal, urethro-vesico- 
 vaginal, vesico-vaginal, vesico-uterine, uretero-vaginal, and 
 uretero-uterine. 
 
 Etiology. — Malignant disease of the bladder, cervix, or 
 vagina may establish the fistula. It may be brought about 
 by ulceration resulting from an ill-fitting or a too long- 
 retained vaginal pessary. It may follow a phlegmonous 
 vaginitis or a necrosis of the bladder wall from any cause. 
 It may result from the perforation of fuital bones which 
 have worked their way into the bladder from a suppurating 
 ectopic gestation sac. In the same way a calculus or vesical 
 foreign body may perforate the wall. In the great majority 
 of cases, however, fistula can be attributed to labour. In 
 connection with this process, it may be brought about in two 
 ways, namely, by direct rupture, associated with or without 
 manual or instrumental interference on the part of the 
 accoucheur ; in most instances the fistula follows a slough- 
 ing of tissue succeeding a long-continued pressure of the 
 soft parts against the pubes by the foetal head. 
 
 Pathology. — The most frequent fistula is tliC vesico- 
 vaginal. It varies in size ; in the most extreme case the 
 whole vesico-vaginal septum may be destroyed. Occasion- 
 ally more than one opening is found. Some fistuloe may 
 only admit a probe ; others a finger or two. At first the 
 edges of the fistula are swollen. Later on, as cicatrisation 
 occurs, they become thin and hard. Contraction tends to 
 take place in the opening. When the fistula is large, the 
 mucosa of the bladder may bulge somewhat through. 
 
 The urethra, through disuse, contracts and may become 
 greatly stenosed. The vagina may be contracted as a result 
 
 1 
 
V, 
 
 622 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 of the injury which led to the fistula, and may present 
 cicatricial bands. These may give rise to pockets, in which 
 urine may collect and decompose, leading to calcareous 
 deposit. The cicatrisation may cause the vaginal wall to 
 become closely adherent to the pelvic wall ; this may some- 
 times considerably affect the urethra. 
 
 Cystitis is often present, and ureteritis is sometimes found \ 
 the ureter may be dilated if the cicatrisation abou*: the fistula 
 interferes with the lower end. When the ureter is opened 
 it is usually secondary to a vesico-vaginal fistula ; the vesical 
 wound may heal, leaving the opering into the ureter. 
 Where there is an opening in or near the cervix, the irrita- 
 tion tends to keep up endometritis. 
 
 Symptoms. — When the fistula is established there is an 
 involuntary flow of urine into the vagina. In connection 
 with labour, if the cause be a tear, this immediately follows 
 delivery ; if due to pressure and sloughing, it may be de- 
 layed for several days (three to ten). The quantity of 
 urine which escapes depends on the situation and size of 
 the fistula. Where there is a ureteric opening, the bladder 
 acts normally in connection with the normal ureter, but 
 there is a constant dribbling as a result of "^he fistulous 
 opening into the other. 
 
 If a vesico-vaginal fistula be near the cervix, there is only 
 a continuous flow when the patient lies down ; in the erect 
 posture, that part of the bladder below the level of the 
 opening collects a quantity of urine, and if the patient 
 makes water frequently there may be only occasional overflow 
 through the fistula. If the fistula be near the urethra the 
 patient may only be much troubled when standing or walking; 
 when lying on her back she may be able to hold consider- 
 able urine in the bladder. When there is a urethro-vaginal 
 fistula, urine escapes into the vagina only during micturition. 
 
 As a result of the flow of urine in fistulous cases, there 
 is a urinous odour about the patient. The external genitals 
 are tender; they may become excoriated and inflaF<ed. 
 
 (\ 
 
GENITO-URINARY FISTULA. 
 
 623 
 
 The general 
 
 or felt on 
 
 I 
 
 Amenorrhoea and sterility are common, 
 health may become greatly deteriorated. 
 
 Diagnosis. — Large fistulas may be seen 
 vaginal examination. A sound may be 
 passed through the urethra into the vagina 
 by way of the fistula. A small fistula may 
 be very difficult to find, owing to its being 
 hidden by cicatricial bands, to its high 
 situation in the vagina or in the cervix, or 
 to its being somewhat obliquely directed. 
 In such a difficult case, coloured fluid, e.g. 
 milk and water (sterilised), or solution of 
 potassium permanganate, should be injected 
 into the bladder, and its escape should be 
 watched for by way of the vagina, which 
 is dilated with specula ; the vagina should 
 be thoroughly dried beforehand. Some- 
 times a piece of blotting-paper, placed in 
 the vagina, may be used to catch the first 
 drops of fluid, thus showing the site of the 
 fistula. 
 
 If the fistula communicate with the cervix, 
 it may be well to dilate the cervical canal 
 before making the examination. If the 
 fistula communicate with the ureter only, 
 injection of the bladder is not followed by 
 any escape through the vagina. Sometimes 
 the urine may be seen to escape from the 
 ureteric opening by little jets. 
 
 Treatment. — For many years the opera- 
 tive methods employed for the closure of 
 vesico-vagir"! fistula have been based upon 
 the princip ' ^id down by Marion Sims, i.e. 
 free paring or the edges of the fistula, and adaptation of the 
 raw surfaces by means cf sutures. Sims was not the first to 
 suggest this method. It is certain that it was recommended 
 
 Fig. 234.— Right 
 and left vesico- 
 vaginal fistula 
 knives. 
 
 
V 
 
 624 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 by Van Roonhuysen of Holland, in the seventeenth century, 
 and that Fatio of Basel and others employed it successfully 
 in the eighteenth century. 
 
 In the early part of the present century. Hay ward of 
 Boston, U.S.A., pointed out the necessity of making a large 
 raw ourface, while Mettaner of Virginia advocated the use 
 of the silver suture. 
 
 It is, however, to Marion Sims, and later to Simon, that 
 we are mainly indebted for the elaboration of the operation, 
 and for the demonstration of its superiority over the other 
 
 mucosa. 
 
 Vaginal 
 mucosa. 
 
 Sims' operation. 
 
 SSffiS^^SS?^^- 
 
 - Vesical 
 mucosa. 
 
 Vaginal 
 
 mucosa. 
 
 Simon's operation. 
 Fig. 235. 
 
 methods of treatment. They have, indeed, made universal 
 the plastic operation as the only reliable means of treating 
 fistulae. Yet, important as the results of their methods 
 have been, there can be no doubt that better results can be 
 obtained by the employment of certain modifications, both 
 in regard to the manner of preparing the raw surfaces and 
 of uniting them. 
 
 Sims and Simon recommended that the edges of the 
 fistula should be rawed by the removal of a strip of tissue, 
 extending from the vaginal to the vesical mucosa. The 
 former pared the edges by a sloping incision, which did not 
 
 l\ 
 
GENITO-URINARY FISTULA. 
 
 divide the latter, but passed close to it. Simon made an 
 incision less sloping, which did not specially avoid the 
 vesical mucosa. 
 
 The improvements upon these methods which are to be 
 recommended may be best considered in relation to the 
 following varieties of fistula, classified according to size : — 
 
 1. Very small. 
 
 2. Small or medium. 
 
 3. Large. 
 
 4. Very large. 
 
 (a) With lower edge not cicatrised close to pubes. 
 (p) With lower edge cicatrised close to pubes. 
 
 5. Utero-vesico-vaginal. 
 
 6. Utero-vesical. 
 
 7. Urethro-vaginal. 
 
 8. Uretero-vaginal. 
 
 9. Uretero-cervical. 
 10. Incurable. 
 
 1. Very small fistulae, i.e. those through which only a 
 probe or sound may be passed. 
 
 In these cases it is entirely unnecessary to employ the 
 Sims or Simon method. The following plan is more easily 
 carried out, and is thoroughly effective. 
 
 The patient is placed in the lithotomy position. The 
 cervix uteri is drawn down, and the anterior vaginal wall 
 exposed, as in the operation of anterior colporrhaphy. 
 
 A small oval flap of vaginal mucosa, \ in. or \ in. in 
 diameter, is dissected from the anterior wall of the vagina, 
 the fistula being in the centre of the flap. 
 
 Then, with a continuous catgut suture, applied in two 
 or three stages, the raw surface is closed until only a 
 longitudinal wound is left. In this way the fistula is 
 covered by a thick mass of vaginal tissue. 
 
 2. Small or medium-sized flstulse, in which there has 
 been no loss of tissue, and whose edges may be approxi- 
 mated fairly closely. 
 
 46 
 
V. 
 
 626 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 Here it is not a good principle to remove a strip of tissue, 
 as recommended by Sims and Simon. Every gynecologist 
 has had experience of ill-success by the use of their methods 
 in these cases. Sometimes this is due to too great tension 
 on the stitches. Sometimes, in fear of this danger, too small 
 an amount of tissue is removed, co that either non-union or 
 only partial union results. In successive attempts new raw 
 surfaces are obtained only by renewed paring of the edges. 
 
 Fk;. 236. 
 
 h. 
 
 a. Raw surface with fistula in its centre, and first stage of continuous 
 
 suture. 
 
 b. Appearance of vaginal wall after closure of raw surface. 
 
 Such cases may require five, six, or more operations before 
 permanent cure can be effected. 
 
 There can be no doubt that the method of denuda- 
 tion by removal of tissue is bad in these cases. Just 
 as in the operation for perineal repair, this principle has 
 been displaced by the flap operations of Lawson Tait 
 and A. R. Simpson, so the Sims and Simon methods 
 must be abandoned, in the cases of vesico-vaginal fistula 
 
 h 
 
GENl TO- URINA R Y FIS TULA. 
 
 627 
 
 now under consideration, for the flap-method introduced 
 by Walcher, called by the French anto-plastie par dcdouble- 
 inent. 
 
 The operation should be i)erformed as follows : — The 
 patient is placed in the lithotomy position, the anterior 
 vaginal wall being exposed in the ordinary manner, and 
 steadied with forceps applied near the fistula. The edge of 
 
 Incision in edge o/Jistula. 
 
 j2:SS2Z?._ Vesical 
 
 mucosa. 
 
 '~~—^ Vagina I 
 
 mucosa. 
 
 Lateral incision 
 
 j\^ in paginal 
 
 mucosa 
 
 Fig. 237. 
 
 a. Edge of fistula with incision. 
 
 b. Flaps separated and suture passed. 
 
 c. Raw surface of flaps approximated. 
 
 the fistula is then divided to the depth of \ in. or there- 
 abouts, so that a vaginal and a vesical flap are formed. In 
 the operation originally described by Walcher this was 
 preceded by the removal of a thin strip of tissue from the 
 extreme edge of the fistula. Winckel, however, in an im- 
 
 I 
 
628 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 portant paper, which he published in 1891, highly recom- 
 mending this new method, showed that such a step was 
 unnecessary. If the vesical flap be now pushed inwards, 
 and the vaginal flap pulled outwards, it will be seen that a 
 large raw surface exists all round the fistula. Sutures are 
 next applied. Walcher brought the vesical flaps together 
 with catgut, and the vaginal flaps with silk. This is not 
 necessary. Catgut alone may be employed either by the 
 continuous method or by separate sutures. In either case 
 a deep series should be first passed, each one entering 
 the raw tissue just inside the edge of the vaginal mucosa, 
 and emerging close to the vesical mucosa. Afterwards a 
 superficial set should be used to close the edges of the 
 vaginal mucosa. 
 
 In certain cases, if it be feared that the tension of the 
 stitches is excessive, a simple means of relieving it may 
 be adopted. Before the sutures are applied a longitudinal 
 incision \ in. or \ in. in length may be made through the 
 mucosa of the anterior vaginal wall, somewhere near the 
 outer border of the wall. As a result of this incision 
 the vaginal flaps at the edge of the fistula may be more 
 readily approximated. This may be carried out on both 
 sides, if necessary. 
 
 After the closure of the fistula, these lateral incisions, 
 which have been made to gape, may be closed more or less 
 thoroughly, the sutures being passed at right angles to the 
 original incision. 
 
 3. Large fistulsB, in which there has beeii some loss of 
 tissue. When the fistula is large, and its edges cannot be 
 approximated owing to the loss of tissue which has 
 occurred, it is useless to attempt its closure by the ?'ms 
 method or even by dedoublement. 
 
 For such cases the following method may be tried. It 
 has been described by Professor Ferguson of Chicago, in 
 the American Journal of Obstetrics for April 1895. It 
 was, however, first employed and recommended by Martin 
 
 h. 
 
GENITO-URINARY FISTULA. 
 
 629 
 
 of Berlin in 1891. The operation is based upon Volkmann's 
 procedure in ectopia vesicae. 
 
 The patient is placed in the lithotomy position. The 
 anterior wall is well exposed, and held with three or four 
 pairs of forceps. An incision is made through the vaginal 
 mucosa around the fistula, at a distance from its edge of 
 little more than half the average transverse diameter of the 
 opening. This flap is then dissected almost to the edge of 
 
 /Fistula 
 
 Incision. 
 
 Vesical 
 mucosa. 
 
 Vaginal 
 mucosa. 
 
 a. 
 
 smi3:iZES2:i21i3!i_ 
 
 ^SEgsssaasEss 
 
 Part o/raiv surface lejt 
 to granulate. 
 
 Fig. 238. 
 
 a. Incision around fistula. 
 
 b. Flap turned inwards and suture introduced. 
 
 c. Raw surfaces of flap approximated by means of suture. 
 
 I 
 
 the fistula, and is then turned inwards so as to bridge across 
 the opening. 
 
 It is thus evident that the vaginal surface of the flap has 
 been turned towards the bladder, while a considerable raw 
 surface looks towards the vagina, part of which belongs to 
 the flap, part to the vaginal wall from which it was dissected. 
 
 1% 
 
630 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 
 The edges of the flap are next brought together with catgut, 
 and the whole raw surface is closed as much as possible 
 with continuous catgut suture, just as in the operation of 
 colporrhaphy. 
 
 If necessary, the lateral incisions, recommended in the 
 last-described operation, may be made, in order to allow of 
 the approximation of the edges of the wound with as little 
 tension as possible. 
 
 If the raw surface be too large to allow of complete 
 closure, the vaginal edges of the wound may be left un- 
 stitched, in order to heal by granulation. 
 
 By this method it is seen that the turned-in surface of 
 the vaginal flap becomes the inner surface of the restored 
 bladder-base. 
 
 If this method should not be completely successful after 
 
 one operation, any fistulous 
 tract remaining can be closed 
 by a subsequent plastic pro- 
 cedure. 
 
 Stanmore Bishop has 
 recommended the following 
 method in such cases : — 
 
 A circular incision is made 
 around the fistula, passing 
 through the mucosa and part 
 of the underlying tissue, so 
 that a continuous flap can be 
 raised and separated near to 
 but not through the edge of 
 the fistula. Through four 
 equidistant points in the 
 margin of the turned-in flap 
 threads are passed, their outer 
 free ends being knotted. 
 Then a curved pair of forceps is passed through the urethra 
 until its beak reaches the fistula, where it grasps the knotted 
 
 Fig, 239. — Bishop's operation 
 for vesico-vaginal fistula. 
 
 \\ 
 
GENITO- URINAR Y FISTULA. 
 
 63 « 
 
 ends of the four threads. These are thereby drawn through 
 the bladder and out through the urethra, (lentle traction 
 is made on the threads so as to invert the circular flap 
 into the bladder. Just before this inversion, however, 
 the edges of the flap are well approximated by means 
 of a fine silk suture carried round the flap near its free 
 margin. It is tightened and tied just after the process 
 of inversion. 
 
 The urethral threads are then drawn upon, further in- 
 verting the flap, and the raw surfaces may be still more 
 approximated by means of another circular suture. In this 
 way the fistula is closed. 
 
 The urethral threads are then cut and withdrawn. 
 
 4. Very large fistula.^ — (a) Those in which the lower 
 edge of the fistula has not been cica^^rised close to the 
 pubic bone. 
 
 For such cases there can be no doubt as to the superi- 
 ority of Mackenrodt's method. This is as follov/s : — 
 After fixing the cervix and anterior vaginal wall with 
 forceps, a mesial longitudinal incision is made through the 
 base of the bladder and the vaginal wall at the lower and 
 upper parts of the fistula, which is thereby made continuous 
 with the incisions. In this way the bladder is opened from 
 cervix to urethra. The edge of the whole opening is then 
 split, so that the bladder is thereby separated from the 
 vagina for a short extent around the edge. 
 
 The bladder is also separated from the cervix for a 
 
 
 ^ Other methods of treating these fistulai are not to be recommended. 
 I refer to such as the following : — Trendelenburg {Detilsche vied. 
 IVchnschr., Leipzig, 1892, No. 23, S. 518) opened into the bladder 
 extraperitoneally from above, cutting through the abdominal wall 
 close to the upper margin of the symphysis. Wikhoff ( IVien. kliit. 
 Wchnschr., 1893, No. ii, S. 195) tried the same plan, performing 
 symphyseotomy in addition ; the latter procedure gave no advantage, 
 scarcely any separation of the bones being obtainable. Dittel ( IVien. 
 klin. Wchnschr.^ 1893, No. 25, S. 448) performed a laparotomy, 
 separating the cervix from the bladder and then closing the fistula. 
 
V 
 
 632 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 considerable distance from the upper end of the incision. 
 In this way it is made possible to bring the edges of 
 the bladder wall into apposition at the fistula. These 
 are next united by a series of catgut sutures, extending 
 from the cervix to the urethra. Afterwards, the vaginal 
 flaps of the fistulous margin are sutured. If there be 
 any difficulty in carrying out the closure of the latter at 
 the upper angle of the wound, the cervix may be drawn 
 down and the vaginal flaps stitched to its posterior rawed 
 surface. 
 
 {b) Those in which the lower edge of the fistula is cica- 
 trised close to the pubes. 
 
 For these the method advocated by Schauta is the best 
 yet devised. A vertical incision is made through the labium 
 majus on the side on which the cicatrisation exists. It is 
 carried deeply as far as the ramus. Then, with the finger 
 and a spatula, the vaginal wall along the cicatrised edge of 
 the fistula is separated from the bone. The wound i hen 
 stuffed with gau/^e, while the edges of the fistula, which are 
 now easily brought together, are rawed and closed. After- 
 wards, the outer wound is closed. 
 
 5. Utero-vesico-vaginal fistulse, those in which at the 
 apex of a tear in the cervix there is an opening into the 
 bladder. 
 
 These may be closed simply by making a raw surface 
 around the fistula, and closing it with continuous catgut. 
 To get a complete exposure of the opening it may be 
 necessary to split the cervix at some point. 
 
 This method may not be successful if the fistula be 
 difficult of access, and it does not leave the woman free 
 from danger of reopening at another confinement. It is 
 therefore better to employ the operation used in tlie treat- 
 ment of utero-vesical fistula, next to be described. 
 
 6. Utero-vesical fistulse. — For these there can be no 
 doubt that the following method is the best. A transverse 
 incision is made in the anterior fornix, and the bladder 
 
 rV 
 
GEN I TO' URINA R Y FIS TUL A. 
 
 633 
 
 separated from the cervix as far up as is necessary to allow 
 the fistulous tract to be well exposed. 
 
 The vesical and cervical portions of the tract are then 
 closed separately with catgut sutures. Afterwards, the 
 wound in the anterior fornix is closed. 
 
 Fig. 240. — Rolpokleisis. The diagram represents the appHcatioii 
 of the sutures after the raw surfaces are made. 
 
 
 
 i 
 
 This method was first employed in England by Champ- 
 neys, but it has also been used successfully abroad by 
 FoUet, VVolfler, Winternitz, and others. 
 
 All these operations should be preceded by the most 
 thorough disinfection of the mucosa of bladder, vagina, 
 and uterus ; the strictest antiseptic precautions being ob- 
 served during the operation. 
 
 Catgut is sufficient for all sutures, Lister's chromic gut, 
 Nos. 2 and 3, being serviceable ; it should, however, be 
 thoroughly soaked in carbolic lotion (i to 20) before use. 
 The best needles are Martin's small full-curved variety ; his 
 simple needle-holder is also the best. 
 
IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 1.0 
 
 I.I 
 
 1.25 
 
 2.8 
 
 1^ ^ 
 
 IS m 
 
 ^ 1^ 
 
 1^ 
 
 M 
 
 1.8 
 
 i.4 ill 1.6 
 
 Photographic 
 
 Sciences 
 Corporation 
 
 ■23 WEST MAIN STREET 
 
 WEBSTER, N.Y. 14580 
 
 (716) 872-4503 
 
' WJ'.. 
 
 ^ 
 
 1 
 
 ;V 
 
634 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 After the operation it is probably best to drain the 
 bladder, per urethram, by a soft metal catheter. One 
 should be used at night and another during the day, the 
 unemployed one being kept in an antiseptic lotion. The 
 catheter must be passed carefully, so as not to tear the 
 wound in the base of the bladder. After five or six days 
 the patient may be allowed to make water at short in- 
 tervals. 
 
 Iodoform pessaries may be introduced daily into the 
 vagina for the first few days ; afterwards an antiseptic douche 
 may also be carefully given. 
 
 Ammonium benzoate or salol may be given for a week or 
 two by the mouth. 
 
 7. Urethro-vaginal fistulse. — These may be closed by 
 either of the methods described on pp. 625, 627. 
 
 When a urethral as well as a vaginal fistula exists, the 
 former should be closed first. 
 
 8. Uretero - vaginal fistulse. — Different methods are 
 employed for the closure of these fistulas. 
 
 Pozzi's flap-operation is a good one. A transverse 
 incision is made through the vaginal mucosa at the level 
 of the fistula, extending outwards on each side for about 
 three-eighths of an inch. At each end an incision is made 
 at right angles. Each flap is dissected back for about 
 three-eighths of an inch. They are raised, and the fistula is 
 seen in the centre of the raw surface. The flaps are then 
 drawn together, their raw surfaces being in apposition. 
 Stitches are carefully applied. 
 
 Landau adopts another plan. If there be no large open- 
 ing into the bladder in connectioii with the fistula, he 
 makes one by the removal of an oval strip in the direction 
 of the ureter. A fine elastic catheter is passed into the 
 ureter, and carried into the bladder through the urethra. 
 A raw surface is made around the fistula, and then closed 
 with stitches, care being taken not to pass them around the 
 catheter. The catheter is left in situ for several days. 
 
GENITO-URINARY FISTULA. 
 
 ^ 
 
 9. Uretero-cervical fistulae. — These cannot be repaired 
 successfully. Closure of the vagina or removal of the kidney 
 on the affected side may be recommended. 
 
 10. Incurable urinary fistulae. — Closure of the vagina or 
 kolpokleisis may be recommended. First of all, if there be 
 no large communication between the bladder and vagina, 
 one should be made by excising a portion of the walls. 
 The opening should be about two-thirds of an inch m 
 diameter. After the edges of the incision have healed 
 closure of the vagina is carried out. A circular ring of 
 
 i 
 
 Fig. 241. — Pozzi's method of closing a uretero-vagiii.al fistula. 
 
 vaginal mucosa is dissected off, half an inch or more in 
 width. The raw surfaces are brought together with silk- 
 worm gut or linen sutures. 
 
 The patient is placed in bed, and treated as after a 
 vesico -vaginal fistula operation. 
 
 When healing takes place, it is evident that the upper 
 part of the vagina has been transformed into a diverticulum 
 of the bladder. Menstruation thereafter occurs by way of 
 the uredi:-a. 
 
 If hremcrrhage occur from the wound, vaginal plugging 
 may be necessary, if a hot douche does not check it. If 
 the bladder fills with clot, the urethra should be dilated 
 and the clot broken up with a wire loop. 
 
 When haemorrhage cannot be stopped, fresh stitches must 
 be applied. 
 
636 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 Should the urtter be hurt, or included in a ligature, there 
 is pain in the loins, vomiting, and rise of temperature. In 
 such a case the offending ligature must be removed ; other- 
 wise, it will ulcerate through the ureter. 
 
 Incontinence of urine may last after the fistula has been 
 closed, from loss of tone in the muscular fibres surrounding 
 the urethra owing to disuse. 
 
 For this condition various medical means are tried — e.^. 
 electricity, strychnine, massage, hot douches. Some recom- 
 mend the removal of a small amount of tissue in order to 
 diminish the calibre of the outer portion of the urethra. 
 
 Disorders of Micturition. 
 
 Irritability of the bladder. — This condition may be 
 used to include all cases in which a woman micturates 
 or desires to micturate frequently. It may be due to 
 states of the urine, e.g. highly acid urine, abundant urates 
 in the gouty, excess of phosphates in nervous women, 
 oxaluria. 
 
 Various affections of the bladder and urethra may cause 
 it, e.g. cystitis, contracted bladder, calculus, nev^ growth, 
 fissure of urethra, caruncle, urethritis ; it may be due merely 
 to a full bladder. It may be associated with various affections 
 in neighbouring partSj e.g. spellings of all kinds pressing on 
 the bladder, prolapsus uteri ; or it may be reflex, from such 
 conditions as fissure of the anus, piles, intestinal worms, irri- 
 tating vaginal and vulvar discharges, operations in various 
 parts of the pelvis. It may be due to certain conditions of 
 the kidney, e.g. chronic Bright's disease, acute parenchy- 
 matous nephritis, sometimes cystic degeneration, stone, 
 pyelonephritis, tuberculosis. 
 
 It is found in certain remote diseases, e.g. diabetes, in 
 certain conditions of locomotor ataxia. It may occur in 
 neurotic or hysterical women, in times of emotional excite- 
 ment, and in various mental states. It is found in early and 
 
D/SOKDEKS OF MICTURITION. 
 
 037 
 
 in late pregnancy. It is important to distinguish between 
 this state and the condition of overflow from a distended 
 bladder. 
 
 Retention of urine, complete or partial, is the state in 
 which normal emptying of the bladder does not take place. 
 It may be found in a variety of conditions, e.g. in such 
 conditions as fevers, shock, injury to brain and spinal cord, 
 general paralysis, various kinds of insanity, locomotor ataxia, 
 myelitis of cord, hysteria ; neighbouring inflammations, e.g. 
 acute peritonitis, cellulitis ; pressure on the neck of the 
 bladder, e.g. by tumours, retroversion of the gravid uterus ; 
 obstruction in the urethra, e.g. polypus, blood clot, cal- 
 culus ; contraction of sphincter may be caused by various 
 local conditions, e.g. acute gonorrhoea, operations on various 
 pelvic conditions, t.g. piles. 
 
 Incontinence of urine may be markqd by continuous 
 dribbling or by intermittent evacuations. This condition 
 may be found in hysteria ; in various injuries or diseases of 
 the brain and spinal cord where the sphincter power of the 
 neck of the bladder and urethra is lost, e.g. in certain stages 
 of locomotor ataxia, epilepsy ; in advanced tuberculosis 
 impairing the sphincter action ; in vesico- vaginal fistula ; 
 dilatation of the urethra ; intoxication ; in various forms 
 of stupor, e.g. typhoid state ; it may be due to strong 
 stimuli acting on the bladder, urethra, or neighbouring 
 parts, e.g. applications to neck of bladder or inner end 
 of urethra; acute cystitis, calculus, sudden submucous 
 haemorrhages, caruncle, fissures, inflammation in tubes, 
 ovaries, uterus, rectum ; it may be found in early preg- 
 nancy. 
 
 In childhood there may be a true incontinence due to 
 sphincter paralysis, hyperesthesia of the vesical mucosa, 
 some localised trouble, or a nervous condition ; but in the 
 majority of cases the irritation is reflex, from such conditions 
 as oxaluria, lithaemia, worms in the bowel or vagina, polypi 
 of rectum, eczema of vulva or perineum, etc., and is in most 
 
638 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 cases only found at night. Once the habit is formed, it may 
 rem.ain long after the cause is removed. 
 
 It is of great importance to distinguish between incon- 
 tinence of the above varieties, and that which is due to the 
 dribbling overflow of a distended bladder, such as may be 
 found in locomotor ataxia and some other nervous diseases, 
 in retroflexion of the gravid 'iterus, etc. 
 
 Pains in the urinary tract. — Pain in the bladder may be 
 continuous or only at times of micturition ; it may be due 
 to actual disease, e.g. cystitis, tuberculosis, new growth, 
 especially carcinoma, calculus. The differences in this symp- 
 tom I have considered under the various headings. The 
 pain may be out of all proportion to the lesion, i.e. the 
 patient may be extremely sensitive or neurotic. In some 
 cases of neurosis there may be no local lesion whatever. 
 It may be due to organic nerve disease, e.g. locomotor 
 ataxia. 
 
 Bladder pain may be merely referred, e.g. from the 
 kidney. There may be disease in the kidney, such as 
 stone or tuberculosis, and the pain may be felt only in the 
 bladder. Or it may be referred from several diseased con- 
 ditions in the pelvis. Thus Fenwick says that stone in the 
 bladder may be simulated by a variety of conditions. It 
 is important, also, to note that the bladder may be the seat 
 of diseas^^, though the pain may be referred to some other 
 part, e.g. kidney, sacrum. 
 
 Pain in the urethra may be due to inflammation, new 
 growth, cai uncle, fissure ; it may be referred from bladder, 
 from extravesicalj pelvic, or renal states. ' 
 
 Pain in the ureter may be caused by the passage along it 
 of a stone, blood clot, a slough, a mass of debris, e.g. muco- 
 pus ; it may be due to ureteritis ; it may be owing to various 
 renal conditions, e.g. stone, etc., especially those which tend 
 to block its upper end \ it may be found in twists or con- 
 strictions of the tube. 
 
 Pain in the kidney is felt in different conditions, though 
 
 P 
 
DISORDEJiS OF MICTURITION. 
 
 639 
 
 there are great variations. Cancer cauFes it usually only in 
 the late stages ; but it may be early, if blood clots ixiss into 
 the kidney pelvis, if the growth be rapil, if stone form, or 
 inflammation occur. Sudden increase of tension, e.^i;. from 
 congestion or back pressure from the lower urinary tract, 
 may produce this dull feeling in the loins. 
 
 Calculus, which is loose in the pelvis, usually causes bad 
 pains, which may be very intense, because of the irritation 
 to the mucous membrane, because of accompanying inflam- 
 mation, or obstruction of the ureter. In some cases very 
 large stones may be present in the kidney without any 
 symptoms, or with only an occasional aching in the loins. 
 
 In tuberculosis there is generally only a dull feeling in 
 the loins, but where the pelvis of the kidney is affected 
 there may be severe pains. Hydronephrosis, developed 
 slowly, is usually accompanied only by a dull aching in the 
 loins, which may be occasional or constant. If the con- 
 dition is developed quickly, intense pain may be caused. 
 
 It is important to note that in some cases of kidney trouble 
 the pain may be felt elsewhere. Thus stone in one organ 
 may cause symptoms only in the other. The pain may be 
 referred to the ureter, to the bladder, to distant parts, such 
 as the shoulder, groin, thigh, leg. Pain may be caused in 
 the region of the kidneys by organic nervous disease, e.g. 
 locomotor ataxia; in neurotic conditions, bj myalgia in 
 neighbouring fasciae and muscles ; in pleurisy of the lower 
 part of the chest. 
 
 Suppression of urine. — This condition may be due to 
 shock ; to reflex causes, e.g. injury to a kidney, sudden 
 blocking of a ureter, injury to the lower urinary tract, 
 operative procedures ; to acute septic changes spreading 
 to the kidneys ; sometimes it is found in acute Bright's 
 disease ; sometimes in advanced inflammatory and cirrhotic 
 forms of Bright's disease; rarely, it is found in hysteria. 
 It may be caused by impaction of calculi in both ureters ; 
 by stricture of both ureters in advanced carcinoma in the 
 
 ;! 
 
640 AFFECTIONS OF THE URETHRA AND BLADDER. 
 
 pelvis ; impaction of a calculus in a ureter, the kidney of 
 the opposite side being destroyed ; new growth of bladder 
 implicating both ureters. Thus suppression may be 
 absolute, or a little urine may be passed. The condition 
 must be distinguished from retention. 
 
CHAPTER XXII. 
 
 CERTAIN AFFECTIONS OF THE RECTUM. 
 
 Bectocele. — In this condition there is a protrusion of the 
 lower part of the anterior rectal wall along with the posterior 
 vaginal wall into the vaginal slit. I have already referred 
 to it {vide p. 576). 
 
 Prolapse of the rectum. — This may be partial, when only 
 the mucosa is prolapsed, or complete, when the whole wall 
 is down. The former is the most common. 
 
 Etiology. — It may be due to the dragging down of piles 
 or new growths attached to the mucosa, to inflammatory 
 exudation outside the mucosa ; chiefly, to severe or pro- 
 longed expulsive efforts, especially where the anal sphincters 
 are relaxed ', thus it may be found in all conditions where 
 the patient has to strain hard to make water. Sometimes it 
 is due to parasites in the bowel or to diarrhoea. It is more 
 common in early than in advanced age. Complete may 
 follow partial prolapse. 
 
 Physical signs. — In partial prolapse, the red protruding 
 mucosa is visible, the sulci between the folds radiating from 
 the lumen ; the mass does not reach a large size. After 
 defsecation the mass may be returned ; in old cases replace- 
 ment may be difficult, and prolapse may develop at times 
 other than defaecation. There may be a muco-purulent 
 discharge, and slight bleeding often occurs. 
 
 In complete prolapse, a large mass may be formed out- 
 side the £nus. on which the sulci between the mucosal 
 folds are mainly parallel to the margin of the anus. The 
 41 
 
 '1 
 f 
 
 ! ■ 
 
 
 i_. ,_i 
 
64a 
 
 CERTAIN AFFECTIONS OF THE RECTUM. 
 
 peritoneum descends with the prolapse especially in front, 
 and surrounds it except where the mesorectum is attached. 
 Hernia of intestine may take place into, the peritoneal 
 pouch. The prolapse may rupture, may ulcerate or slough, 
 and peritonitis may follow. 
 
 Treatment. — The prolapse should be reduced. If neces- 
 sary, a pad may be placed over the anus, and the nates 
 fastened together with plaster. In many slight cases it is 
 sufficient to oee that the bowels are regulated carefully, and 
 that they are moved in the dorsal or lateral posture ; it 
 is best to do this at bedtime, so that rest follows the act. 
 The anus may be washed with cold water, alum, or oak- 
 bark lotion. In some cases more active measures are 
 necessary. 
 
 Where the prolapse is not great nor of long standing it 
 may be sufficient, after reduction of the prolapse, to dilate 
 the anus with a speculum, and to cauterise the mucosa by 
 a dull red point in a series of vertical lines extending from 
 3 to 4 in, above the anus, down to the junction of the 
 anal mucosa and skin. The patient is then kept in bed for 
 a week or two, the bed-pan being used for two weeks or 
 more when the bowels are moved, enemata of warm water 
 being given to help defaecation. 
 
 Where this method fails, or in cases where the prolapse is 
 of old standing, Robert's operation may be performed. 1 ne 
 bowel is cleansed and reduced, the patient being in the 
 lithotomy posture. 
 
 A mesial incision is made into the skin just in front of 
 the coccyx. With a finger the posterior connections of the 
 bowel are separated. Then with a bistoury a triangular 
 piece of tissue is removed, including skin, cellular tissue, 
 and sphincter ; the base of the triangle is the margin of the 
 anus. Next a triangular piece of the posterior bowel wall 
 is removed, the apex being about 3 in. from the anus. 
 The edges of the rectal incision are then tied with catgut 
 sutures on the mucosal surface. The outer wound is then 
 
 W 
 
F/SSURE OF THE ANUS. 
 
 643 
 
 closed. Afterwards, iodoform pessaries should be passed 
 into the anus daily. " • 
 
 In irreducible cases Mikulicz's plan may be tried. The 
 outer covering of the prolapsed portion is divided trans- 
 versely in its anterior half by an incision from two-fifths to 
 three-fifths of an inch from the anus. Then an incision is 
 made on the posterior half at from three-eighths to six-eighths 
 from the anus. If a hernia of small intestine be found on 
 reaching the peritoneum, it should be reduced, the sphincter 
 ani being cut if necessary to effect this. 
 
 A strip of the anterior portion of bowel wall is dissected 
 off, and the edges of the raw surface are brought together 
 with sutures. The same procedure is carried out on the 
 posterior position. Then the gut is reduced, and iodoform 
 pessaries introduced. 
 
 Fissure of the anus. — This is an ulcer or crack in the 
 mucosa internal to the anal opening, or in the skin at the 
 opening. It leads to pain of a distressing nature, especially 
 after cofaecation. There is pain on examination with a 
 finger. It may cause vaginismus, and pains may be 
 reflected to other parts, e.g. loins, groins. 
 
 Treatment. — A good plan consists in passing a tenotomy 
 knife under the base of the fissure, and cutting through it, 
 dividing the fibres of the sphincter close to it. Equally 
 good is the plan of stretching the sphincter, so as to 
 paralyse it for a few days. In addition, some operators 
 prefer to cut away the ulcer or fissure. 
 
 Haemorrhoids or piles. — These are very common in 
 women. For an account of the condition a work on 
 surgery should be consulted. 
 
 Becto-vaginal fistula. — This condition is caused by 
 rupture in labour, by necrosis following long-continued 
 pressure of the head, by the ulceration of a foreign body, 
 by carcinoma, by abscess formation. 
 
 Treatment. — Where cancer is not the cause, the following 
 method may be employed. Small fistulae may be made to 
 
 \ 1 
 
«4« 
 
 CERTAIN AFFECTIONS OF THE RECTUM. 
 
 heal by the use of the cautery or nitrate of silvei-. If of 
 some size, operative repair is to be carried out. 'J'he same 
 principles are to be observed as have been noted in the 
 repair of vesico-vaginal fistulse. 
 
 Thus a posterior colporrhaphy may be sufficient to bring 
 about closure. The dedoublement melhod is valuable in 
 some cases. When the tistula is low in the recto- vaginal 
 septum, it is best to divide the perineal body iii the middle 
 line below the fistula and then to repair the parts as in the 
 case of a complete tear into the anus. 
 
 Rectal fistula. — This may be complete, when it extends 
 from the skin to the mucosa, or it may be incomplete, where 
 there is only one opening; of the latter, there are two 
 varieties, m one of which the opening is internal — blind 
 internal fistula ; in the other of which it is external — blind 
 external fistula. 
 
 Most commonly the cause is ischio-rectal abscess, which 
 may be independent of or due to changes in the bowel wall. 
 Sometimes there may be more than one external opening, 
 but there is usually only one internal. Sometimes the 
 internal and external openings may be on opposite sides of 
 the bowel, " horse-shoe " fistula. On examining the patient 
 the internal opening is hard to find. 
 
 The condition is a distressing one, causing escape of gas 
 or fcecal discharge and incomplete fistula, sometimes blood. 
 Tenesmus may be present. If the fistula get blocked, 
 pain may be set up and a second suppuration st:;rted. 
 
 Treatment. — If the tissue around the fistula is in a healthy 
 condition, the following plan may be carried out : — 
 
 A probe is passed to the top of the fistula into the bowel. 
 With a bistoury the tissues are divided from the anus to 
 the probe. Any secondary sinus or fistula is then opened 
 up, and the fistulous surface is curetted until it is raw. 
 The wound and the bowel are thoroughly cleansed with 
 an antiseptic, and then the raw surface is completely 
 closed with continuous catgut or with interrupted sutures. 
 
/RECTAL FISTi'LA. 
 
 645 
 
 Morphine and iodoform suppositories are passed daily into 
 the bowel. 
 
 When the tissues are not healthy enough to ensure heal- 
 ing, it is best, after incision and curetting, to pack the cavity 
 with iodoform gauze, and to allow gradual healing from the 
 depth of the wound to occur. 
 
 Qonorrhceal inflammation. — Sometimes the rectal mucosa 
 may be the seat of an acute gonorrhoeal purulent inflamma- 
 tion. If there be piles, prohpse of the mucosa, fissure, or 
 relaxation of the sphincter, the liability to infection from the 
 vulvar or vaginal discharge will he greater. The disease 
 causes much pain and local distress. Gonococci are found 
 in the discharge usually. 
 
 Ulceration. — Different forms of ulcers are found. One is 
 associated with congestion in the mucosa ; it tends to be 
 very chronic, has irregular edges, and bleeds occasionally. 
 
 The follicular ulcer may be single or multiple ; it arises in 
 connection with the solitary follicles of the mucosa. I have 
 already described the irritable ulcer in fissure. Ulceration 
 may be due to tuberculosis, and may be primary or second- 
 ary. It may occur in connection with carcinoma. 
 
 New Growths. — The following are the most common 
 benign growths which occur : — 
 
 Adenoma, which grows as a pedunculated, irregularly 
 lobulated mass. 
 
 Fibvoma, which also tends to become polypoidal; this 
 may often be developed directly from internal piles. 
 
 Papilloma, a rare form, polypoidal, with short villous pro- 
 jections, covered with columnar epithelium. A form may 
 grow at the anus, warty in nature, covered with squamous 
 epithelium. 
 
 Symptoms. — Polypi may cause no symptoms in some cases, 
 especially where they are high. When they are low they may 
 cause a feeling of unpleasantness in the bowel, and there 
 may be expulsive efforts, with tenesmus, mucous discharge, 
 bleeding. 
 
 
^ 
 
 646 CERTAIN AFFECTIONS OF THE RECTUM. 
 
 Treatmoit. — These may be removed by drawing down 
 the tumour, applying a pair of forceps to the base of the 
 pedicle, and cutting away the tumour outside the forceps. 
 The latter are left attached for two or three days. Some 
 operators prefer to ligature the pedicle. 
 
 The following malignant growths are found : — 
 
 Carcinoma. — The most common form is the malignant 
 adenoma or columnar-celled epithelioma. The scirrhous, 
 medullary, and colloid forms are also found, and also the 
 squamous epithelioma of the anus. 
 
 The condition may be primary, or it may be secondary to 
 uterine cancer, in which case it grows 4 in. or more above 
 the anus. Primary cancer is most frequent in the lower 
 portion of the rectum. 
 
 The disease may be annular, in nodules, or on one side of 
 the bowel. Sometimes it may be polypoidal. Ulceration 
 may occur, and surrounding parts tend to be infiltrated. 
 The bowel gets con^iricted. Glands get infected ; when 
 the disease begins within the anus, the pelvic and lumbar 
 glands are first involved. When the skin at the anus is 
 diseased the glands of the groin are involved, or these may 
 enlarge where there is extensive infiltration of the pelvic 
 glands. Metastatic growths develop, e.g. in liver, peri- 
 toneum, pancreas, lungs, etc. 
 
 Sarcoma is rare. It has been found as an infiltration 
 inside the anus, or as a mass bulging at the anus. Melanotic 
 sarcoma may rarely be found (according to Virchow the 
 only part of the intestine in which it is found). 
 
 Symptoms. — The symptoms are usually very insidious in 
 the early stages. Pain is a common symptom, but it varies 
 in different cases ; it is usually worst when the anus and 
 surrounding structures are encroached upon. Bleeding 
 is generally present. There is also a foetid discharge in 
 many cases. There may be diarrhoea or constipation, or 
 an alternntion of both these conditions. 
 
 Defaecation may become very painful. The digestion 
 
M\ 
 
 CARCINOMA. 
 
 647 
 
 gets out of order, the health runs down, and cachexia gradually 
 becomes established as toxic matters are absorbed into the 
 system. CEdema of a leg may develop in the later stages. 
 Perforation of the vagina, uterus, or peritoneum may occur. 
 
 Treatment. — Extirpation should be tried in early cases. 
 There are two methods of performing the operation : — 
 
 I. By resection of the coccyx and part of the sacrum. — The 
 patient is placed on her left side. A crescentic incision is 
 made over the sacrum, reaching from the posterior part of the 
 right sacro-iliac joint to the left of the anus. When the bone 
 is exposed the structures attached are divided, and then the 
 sacrum is divided transversely with forceps or chain saw, 
 below the second lowest sacral foramen. The rectum is 
 then separated from surrounding tissues near the anus. 
 
 If possible, the peritoneum should not be opened, but 
 should be stripped upward off the bowel. If it be necessary 
 to open into the peritoneum, the bowel should be drawn 
 down after this is done, and the opening should be closed 
 with sutures well above the disease. The rectum, from 
 the anus upward, is thoroughly separated from surround- 
 ing structures. 
 
 Two courses may now be carried out — {a) In the 
 one case, the lower part of the rectum containing the 
 diseased portion may be entirely removed and the 
 anus closed. The end of the bowel above the line of 
 division is then drawn backwards and stitched to the skin 
 edges below the sacrum, thus forming an artificial anus. 
 The rest of the wound is stuffed with iodoform gauze, and 
 allowed to heal slowly. In such a case, if the posterior 
 vaginal wall be infiltrated, it may also be removed. All 
 glands affected alongside the bowel must be removed. 
 
 {b) In the other case, the piece of rectum containing the 
 disease is removed and the two ends of the bowel are then 
 stitched together, the rest of the wound being stuffed with 
 iodoform gauze. 
 
 When there is plenty of bowel to pull down, Kocher's 
 
 '•% '•/ 
 
 \ ': 
 
v.. 
 
 648 
 
 CERTAIN AFFECTIONS OF THE RECTUM. 
 
 plan of 'suturing it may be tried. Before the division 
 of the gut above the disease a ligature is placed around it 
 just above the line of incision. The bowel is then cut 
 below this ligature, and at the top of the internal sphincter. 
 The mucosa of the anus is then stripped downwards and 
 removed. 
 
 Then, by means of the ligature, the end of the rectum is 
 drawn down through the anal canal, to which it is stitched 
 with a number of sutures. The protruding part of the 
 rectum is cut off below the ligature, which is left attached, 
 and allowed to urop off of its own accord. In this way the 
 bowel contents are kept from infecting the wound. The 
 wound is then stuffed with gauze, which is brought out 
 at the lower end, the skin edges of the upper portion 
 being brought together with interrupted sutures. In three 
 or four days the gauze may be removed, the cavity washed 
 out, and fresh gauze inserted. 
 
 2. By a parasacral incision. — The patient is placed in the 
 lithotomy or left lateral position. An incision is made from 
 behind the anus to the upper end of the gluteal cleft, and 
 thence to the left as far as the posterior inferior iliac spine. 
 The tissues attached to the left edge of the coccyx and 
 lower part of the sacrum are divided, and the rectum is 
 freed from surrounding tissues, as above described. At 
 this stage it is a good plan to plug the rectum as high as 
 possible with iodoform gauze. To exercise traction on the 
 rectum on freeing it, a loop of gauze may be passed 
 around it. With this incision the coccyx may be removed 
 if necessary. 
 
 After the removal of the diseased part, the bowel end may 
 be brought to the anus and treated as above described. 
 
 Note. — In these cases the operation should be preceded by the most 
 careful emptying and cleansing of the bowel. ^ 
 
 When the bowel first moves a few days after the opera- 
 tion, opening medicine should be given, and an oil or 
 
 . I 
 
STRICTURE. 
 
 649 
 
 glycerin enema administered before the motion. When 
 extirpation is impossible, palliative measures must be 
 adopted. Where there is much obstruction, a colotomy 
 may be carried out with advantage to the patient. 
 
 Stricture of the rectum. — This may be due to malignant 
 disease. It may also be due to syphilitic ulceration,or possibly 
 to some other form of ulceration, leading to cicatrisation. 
 It may be due to new growths and other swellings outside 
 the bowel. - ; • 
 
 Symptoms. — These may be very vague. In the non- 
 malignant cases, the most frequent are diarrhoea alternating 
 with constipation. The motions may be narrow, but this 
 condition may be produced where there is no stricture 
 in the rectum. 
 
 Treatment. — Dilatation with bougies may be necessary, 
 and must be carefully carried out. Sometimes division 
 of the stricture may be performed ; the posterior wall of 
 the anus and rectum is also divided back to the sacrum, 
 the wound stuffed with gauze and allowed to heal by 
 granulation. Excision of the stricture has also been carried 
 out. Sometimes it may be necessary to perform colotomy 
 where the stricture is bad and cannot be improved by local 
 means. Where the stricture is due to some condition outside 
 the rectal wall, treatment must be directed to that condition. 
 
 Pruritus ani. — Itchiness about the anus m;iy be a very 
 troublesome affection. It may be due to scabies, pediculi, 
 parasites in the rectum, haemorrhoids, sluggish circulation, 
 fissures, eczema, etc. Continued scratching may lead to 
 eczema, cracks, thickening of the skin. 
 
 In the cases in which there is no discoverable cause, it is 
 possible that there may be a fibrosis of terminal nerves and 
 end organs, such as I have found in pruritus vulvae. 
 
 Treatment. — The digestive tract should be put in order. 
 Stimulants diminished, and the bowels regulated. Regular 
 exercise should be enjoined. Any local causes must be 
 attended to. The various lotions and ointments mentiored 
 
 \ 
 
V. 
 
 6so 
 
 CERTAIN AFFECTIONS OF THE RECTUM. 
 
 in connection with the treatment of pruritus vulvae may 
 be tried. 
 
 Temporary relief may be quickly got by painting the 
 itching part with a solution of silver nitrate in spiritus 
 setheris nitrosi (15 grs. to the ounce). Lassar's paste 
 with 10 minims of ichthyol and 10 grs. of hydrochlorate 
 of cocain is of great value (Jamieson). After it is applied, 
 a piece of absorbent wool may be kept between the nates. 
 
 Coccydynia. — This is a tender or painful condition in the 
 region of the coccyx, and may be considered here. 
 
 It is most pronounced in nervous women, no discoverable 
 lesion being present. It may, however, be due to a fall, a 
 blow, or injury in labour, leading to stretching of ligaments, 
 dislocation, or inflammation. It may be a referred pain in 
 diseases of ovaries, uterus, anus, etc. In some cases there 
 may be a condition of neuritis. 
 
 The pain varies. It may be worse after any kind of 
 strain or exertion, e.g. riding, driving, defaecation, rising 
 from sitting posture. Pressure increases it and may cause 
 the pain to radiate widely. The general health may suffer. 
 
 Treatment. — The neurotic complication must be attended 
 to. Cocain, hypodermically, may be necessary ; sometimes 
 morphine. These drugs, however, must be used with great 
 discretion. 
 
 In some cases, pelvic inflammation, uterine or ovarian 
 displacement, is associated with the pain complained of. 
 In other cases the affection seems to be neuralgic in nature, 
 and not associated with physical change. In others again 
 the pain is distinctly associated with lesions of the coccyx 
 or ligaments attached to it. f 
 
 In the first class of cases the existing pelvic condition 
 should be treated. In the second class, faradic electricity 
 should be employed, one electrode being placed on the 
 coccyx and the other on the sacrum. Two to eight appli- 
 cat'.^ns may suffice. The strength of current should be 
 increased from time to time. 
 
COCCYDYNIA. 
 
 651 
 
 In the third class of cases, extirpation of the coccyx 
 should be carried out. An incision is made through the 
 skin, the bone is separated from the soft tissues attached to 
 it, and is then divided transversely by a chain saw or by 
 bone forceps. 
 
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APPENDIX. 
 
 ♦ 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 At the present time there is universal ignorance as regards 
 the causation of menstruation, its meaning as a sexual cha- 
 racter, and the method by which it has become established 
 among the higher mammalians. 
 
 The following views have been advanced to explain the 
 meaning of the process : — 
 
 I. Relation to Ovulation. 
 
 For a long time it has been believed that ovulation 
 and menstruation are so closely related that they occur at 
 about the same time, the former being the cause of the latter. 
 Of those who hold this view, some think that the blood 
 discharge results from a general pelvic congestion, supposed 
 to be present during the ripening and escape of the ovum. 
 Thus, Matthews Duncan often compared the menstrual 
 flow to the red flag outside the door of an auction-room, 
 which indicates that something is taking place inside. 
 
 Others regard menstruation as a process induced by ovu- 
 lation, necessary to the preparation and development of the 
 ovum, in case it should be fertilised. 
 
 A careful examination of the evidence on which these 
 
 statements are founded reveals their untrustworthiness. It 
 
 is, indeed, a wonder that they have so long been believed. 
 
 - The following facts relating to maturation and escape 
 
 of the ovum are nov definitely ascertained. These pro- 
 
654 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 cesses are usually in operation some time prior to the 
 development of the phenomena of puberty and before 
 menstruation appears ; sometimes they occur in childhood 
 and in foetal life. There is no proof at all that pelvic 
 congestion takes place, either coincident with or secondary 
 to these processes, at any time in a woman's life. 
 
 Ovulation may also occur without menstruation in the 
 dodging period of puberty and of the menopause, or for 
 several years after the menopause, as Hegar has pointed out ; 
 during lactation ; in certain diseased conditions, e.g. anaemia, 
 phthisis, lead poisoning. Pregnancy may take place at any 
 of these times. De Sindty describes an interesting case 
 which he examined of a woman, 38 years of age, who had 
 never menstruated. In the ovaries there was the normal 
 condition of Graafian follicles, and corpora lutea indicating 
 that ovulation had taken place. The body of the uterus 
 •»"as undeveloped. 
 
 Then, in abdominal and post-mortem sections made 
 at all times between menstrual periods, Graafian follicles 
 may be found on the point of rupture or recently rup- 
 tured J and in examinations made during menstruation no 
 sign of ovulation may be visible. 
 
 In this connection it is interesting to note that Heape 
 examined the pelves of forty-two monkeys {Semnopithecus 
 entellus) during their menstrual periods and found evidences 
 of ovulation being in progress in only two cases. 
 
 It is a common observation that extensive disease of 
 both ovaries, e.g. cystoma, suppuration, malignant growth, 
 may not affect the menstrual function to any appreciable 
 extent in many cases. These various facts are sufficient, it 
 seems to me, to overthrow the view that menstruation is a 
 necessary accompaniment or sequel of ovulation. Yet it 
 can scarcely be denied that there is some relationship 
 between the processes. 
 
 Removal of the ovaries is followed by cessation of 
 menstruation, though in a certain number of cases this does 
 
■•"•• 
 
 RELATION TO OVULATION. 
 
 «55 
 
 not happen. As an interesting instance of this may be 
 mentioned Lawson Tait's patient, from whom both ovaries 
 and tubes along with a part of the uterus were removed, 
 menstruation still continuing. 
 
 These exceptions have been carefully considered by 
 several authorities, lately by Bland Sutton. He states that 
 the reported cases have been mostly those in which chronic 
 inflammation in and around the appendages has been 
 present, or those in which operation has been performed 
 for myoma uteri. His explanation of the persistent mens- 
 truation is that either small bits of the ovarv have been 
 left behind, or that in the cases of myoma a submucous 
 tumour may exist, leading to haemorrhages. Many cases 
 have undoubtedly been recorded, in which, after removal 
 of the ovaries for fibroids, menstruation has continued. 
 
 The long-held view of supernumerary ovaries is discarded 
 by Bland Sutton. He thinks that these so-called structures 
 are merely small bits separated from the main mass of the 
 o\ary by deep fissures. In several of these cases of 
 unchecked mensti uation, second operations have been 
 performed by which small bits of ovary left from the first 
 operation have been removed, being followed by a com- 
 plete cessation. , 
 
 II. Relation to the Fallopian Tubes. 
 
 According to Lawson Tait, removal of the tubes, the 
 ovaries being left out in sitr, is followed in 95 per cent, 
 of cases by cessation of menstruation. This remarkable 
 statement has been little noticed. If it can be established 
 by extended observations, it proves that there is some close 
 relationship between the tubes and the menstrual process. 
 
 III. Relation to a Special Nervous Mechanism. 
 
 '- Johnstone has advanced the view, supported by Lawson 
 Tait and others, that the menstrual act is a special function 
 
V 
 
 656 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 related to a distinct nervous mechanism. They think that 
 possibly a special nerve trunk, running in the upper part of 
 the broad ligament, may convey the regulating currents. 
 Johnstone suggests iliat when the ovaries or tubes are removed^ 
 menstruation is checked because this neme is ligatured or 
 divided. In the cases in which removal of the appendages 
 is not followed by cessation of the flow, he thinks that the 
 nerve may have escaped division or ligature, owing possibly 
 to its being placed low in the broad ligament. 
 
 While undoubtedly believing in this special nervous 
 mechanism of menstruation, it seems to me that possibly 
 the nerve tract is not so limited as Johnstone suggests. 
 The plexiform nature of the nerves about the uterus is so 
 complex that it is presumable that the impulses affecting 
 the mucosa of the uterine body travel by many routes in 
 the broad ligaments. . ■> ^ 
 
 IV. Relation of Menstruation to Conception. 
 
 a. By some it is believed that menstruation is a process 
 for preparing the uterine mucosa for the engrafting of the 
 fertilised ovum, that it is, in fact, an essential feature. This 
 idea was promulgated when it was thought that the ovum 
 required a connective tissue, free x'rom covering epithelium, 
 to become engrafted on. 
 
 I have repeatedly urged its improbability on the following 
 grounds : — 
 
 {a) In most mammalians below Homo, so far as is known, 
 the ovum grows in relation to the epithelium-covered uterine 
 mucosa, and does not require a connective tissue surface. 
 The uterine epithelium is undoubtedly non-essential, but it 
 is destroyed by degenerative processes and by the tropho- 
 blastic action of the outermost layer of the foetal epiblast. 
 As far as our observations go in human development, the 
 same processes occur there. 
 
 {p) Pregnancy may occur in a girl before the onset of 
 
RELATION OF MENSTRUATION TO CONCEPTION 657 
 
 menstruation ; at a time, therefore, when the mucosa cannot 
 be denuded by that process. 
 
 {c) It may occur during the lactation period, long after 
 the uterine mucosa has been restored, and at a period in 
 which menstruation is in abeyance. 
 
 {d) It may take place in one of the periods of amenor- 
 rhoea during the progress of the menopause. 
 
 {e) It may occur in periods of amenorrhcea due to 
 diseases, e.g. anaemia, phthisis. 
 
 (/) Clinical experience of cases of pregnancy following 
 a single coitus, proves that development of the ovum may 
 begin at any time — not necessarily immediately after mens- 
 truation. (It must be stated that this evidence is of 
 doubtful significance, owing to the uncertainty in our 
 knowledge as to the time it takes the ovum to pass from 
 the ovary down through the genital tract, and as to how 
 long the spermatozoa may live in the tract.) 
 
 {g) Pregnancy may occur in the rudimentary horn of a 
 malformed uterus, menstruation never having taken place 
 in that horn. Whereas, as P. Miiller points out, there is no 
 record of a pregnancy having occurred in the atresic horn 
 of a bicornuate uterus, in which, as we know, menstruation 
 occurs, the blood accumulating above the atresia. 
 
 (h) It may occur years after menstruation has ceased 
 at the supposed menopause. An interesting example is 
 Renaudin's case, in which a woman of 62 was delivered, 
 though she had not menstruated for over ten years. 
 
 (?) In male pseudo-hermaphrodites, where testes but not 
 ovaries are present, vagina, uterus, and tubes may exist, and 
 menstruation may occur regularly or irregularly. 
 
 )S. Another view is to the effect that, along with the 
 maturation of the ovum, the endometrium swells, as the 
 first stage in the formation of a decidua which will receive 
 the ovum if it be fertilised. If fertilisation does not occur, 
 breaking down of the superficial portion, the so-called 
 " menstrual decidua," occurs, and the menstrual discharge 
 4a 
 
658 THE EXPLANATION OF MENSTRUATION. 
 
 takes place ; in this way menstruation may be regarded as 
 the expression of the failure of a process meant to be initial 
 to pregnancy. For, if fertilisation occurs, it is thought 
 that the swollen mucosa advances to form the decidua of 
 pregnancy. 
 
 This view, it is evident, is based upon a fallacious 
 assumption, and my objections to the last-mentioned theory 
 may be quoted to refute it. 
 
 There is no proof whatever that changes in *he mucosa 
 accompany maturation of the ovum ; and the b' :♦: evidence 
 we possess regarding the alterations in the uterine mucosa 
 during menstruation, namely, the observations of Johnstone, 
 Bland Sutton, Heape, Minot and Mandl, goes to show that 
 practically only blood and sma portions of the lining epi- 
 thelium escape. There is normally no exfoliation of a layer 
 worthy the name " menstrual decidua." 
 
 I think this term is a bad one ; it is to be clearly under- 
 stood that no change occurs in the connective tissue elements 
 of the mucosa during menstruation, namely, enlargement 
 of cells. This cnange only occurs in connection with the 
 influence of a fertilised ovum. 
 
 y. Lowenthal has advanced still another explanation. 
 He believes that menstrual bleeding is neither a physiological 
 function nor an accompaniment of one, but that it is due 
 to innumerable repetitions of an unnatural state of things, 
 namely, the non-fertilisation and death of the ovum. He 
 says that the swelling of the uterine mucosa is the result of 
 the embedding in it of the last ovum discharged from the 
 ovary. If this ovum be fertilised, the swelling mucosa goes 
 on to form the decidua of pregnancy; if no fertilisation 
 takes place, the ovum dies, and as a result of this death a 
 breaking down occurs in the mucosa. He therefore regards 
 the menstrual flow as having all the characteristics and 
 effects of other bodily haemorrhages. 
 
 Lowenthal's view is a piece of speculation without any 
 actual basis. No one knows anything about the unfortunate 
 
 liu 
 
RELATION OF AfENSTRUATlON TO CONCEPTION. 659 
 
 ova which do not fulfil their highest destiny. It is a 
 sympathetic imagination which makes them cling in their 
 downward course to the walls of a repellent uterus, forcing 
 changes upon that organ, in the fond hope that a wandering 
 spermatozoon may cleave to it in consummative union. 
 
 Fanciful, also, the picture of death following bitter dis- 
 appointment, the coincident decay of the dead ovum's 
 resting-place, and the final bearing a^ ^ in a blood-red 
 funeral stream of the fragments of a once active indi- 
 viduality. 
 
 A. Johnstone believes that the simplest definition of 
 menstruation is a periodic wasting away of the corpuscles 
 that are too old to undergo the changes which must occur 
 in connection with the attachment and development of 
 the fertilised ovum. He does not regard the endometrium 
 above the internal os as mucous membrane, but as belong- 
 ing to adenoid tissue. 
 
 Menstruation is for it what the lymph stream is to the lymph 
 glands or the blood stream to the spleen. The development 
 of the corpuscular elements, he thinks, takes place in the 
 endometrium as in the blood glands, spleen, thymus, etc. 
 
 The existence of menstruation in the human female, and 
 its absence in the mammalian orders below the Primates, 
 he explains by postural differences, and by differences in 
 the structure of the endometrium. From his studies he 
 is of the opinion " that nature has supplied the endometrium 
 with an abundant lymph stream, which, in the unimpregnated 
 state, washes away the ripe material to the general circula- 
 tion, exactly as it does any other lymph corpuscle. But in 
 women, where, on account of its erect position, the uterus 
 has to depend on the tenacity of its own fibres for the 
 preservation of its shape, no such thing as loose tissues of a 
 lymphatic network can be depended on. So, to preserve 
 the integrity of the uterine v ;i, the emulgent stream is 
 poured into the cavity of the body, and got rid of through 
 thevagina." .;,::; ,- • -: 
 
66o 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 V. Relation to Body-Metabolism. 
 
 Geddes and Thomson in their " Evolution of Sex " have 
 advanced the theory that the menstrual process is related 
 to the balancing of anabolism and katabolism in the female 
 organism. 
 
 After puberty a surplus is produced in the system, be- 
 cause the anabolic preponderates over the katabolic. When 
 pregnancy occurs, this excess is spent in the nutrition of 
 the ovum during its parasitic intra-uterine life and during 
 lactation. When these methods of using the anabolic 
 surplus are wanting, menstrual losses occur in order that it 
 may be got rid of. 
 
 Biological Considerations. ^ 
 
 Scarcely any attention has been given to the consideration 
 of menstruation in its biological aspects. The speculation 
 of the distinguished biologists, Geddes and Thomson, is 
 one of the most suggestive which has yet been advanced, 
 and it is worthy of an elaborate study. 
 
 The careful investigations of many forms of plant and 
 animal life by zoologists and botanists have enabled the 
 biologist to establish a distinction between " maleness " and 
 " femaleness," not only in terms of morphological characters, 
 but of psychological and physiological reactions. It is only 
 recently, however, that sex differences have been investi- 
 gated on these more subtle and difficult bases of inquiry. 
 Too long have reproduction and sex been considered by 
 themselves as if they were something to be disassociated 
 from the general physiology of the organism. 
 
 The most important sex distinction which has been 
 established is that which has to do with the general 
 metabolism or protoplasmic chemistry of the body. Every 
 liviHg cell and every organism is continually representing 
 two forms of metabolism ; one, the anabolic, by which 
 
 i 
 
BIOLOGICAL CONSIDERATIONS. 
 
 Ml 
 
 nutrition is taken in, waste repaired, energy stored, structure 
 improved or altered; the other, the kataboHc, by which 
 potential is changed into kinetic energy, and movement or 
 activity manifested, structural alterations reduced, and waste 
 created. 
 
 Throughout the animal kingdom, the distinctive and pre- 
 dominant characteristic of the male sex is katabolism, and 
 of the females, anubolism. Generally speaking, the males 
 show activity, continual expenditure of energy, disruptive 
 metabolism ; the females, passivity, quiescence, constructi'^e 
 metabolism. The same distinction is also widely spread in 
 the plant world. 
 
 The lines of inquiry, on which this generalisation has been 
 made, are the following : — 
 
 1. A study of sexual characteristics in the fully developed 
 state, and in the history of the individual. 
 
 2. An investigation into the condition of the lowest forms 
 of animal and plant life, where sex has its beginning. 
 
 3. Observation of normal and pathological changes in 
 the reproductive apparatus. 
 
 4. An experimental inquiry into the nature of the factors 
 which determine sex. 
 
 Details regarding these lines of research are beyond the 
 limits of this chapter, yet some reference must be made 
 to them. 
 
 As regards the differences found in the adult forms in 
 the Invertebrata and among fishes, it may be stated that 
 in general the body temperature is lower in the female. 
 (This is so in many plants.) Their longevity is greater. 
 They are in general larger, and more sluggish in habits. 
 The males expend energy more freely, thus preventing 
 storage accumulation and increase in size. Among birds 
 and mammals, while the general metabolic differences 
 exist, the males are usually larger than the females owing 
 to special factors which have come into operation, and 
 which do not exist in the lower orders of life. Darwin 
 
662 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 and Geddes have explained these. They show that the 
 differences in size in the higher forms are mainly in bones 
 and muscles. This is explained partly by the extra stress 
 and strain thrown on the males while the females are in a 
 state of pregnancy, and caring for the young ; partly by the 
 strengthening effect of fights between the males, the strongest 
 tending by natural selection to perpetuate their kind ; partly 
 by the effects on the female constitution of the excessive 
 reproductive demands found among the higher animals. 
 
 The distinction between the sexes is universally marked 
 in the spermatozoon and ovum, the former being small, 
 active, energising — katabolic ; the latter large, p /e, highly 
 nourished — anabolic. While the metabolic jifferences 
 between male and female have been mainly studied in 
 plants and the lower animals, some work has also been 
 done in the human subject, though here the difficulties are 
 inc'^ased owing to the greater complexity of the organism. 
 
 . xood. — The red corpuscles are more numerous in the 
 male, and the percentage of haemoglobin greater than in 
 woman. The specific gravity is the same until puberty. 
 Afterwards it is higher in men than in women during the 
 sexual life. In old age it is usually higher in women. It is 
 thus evident that the menstrual life is associated with a 
 fall in the specific gravity of the blood. 
 
 Pulse rate. — The pulse rate is slower in men than 
 in women. This holds good for nearly all animals. 
 
 Respiration. — Men produce more carbonic acid than 
 women, as estimated by the breath. After puberty, the 
 amount is nearly double that produced by woman. It in- 
 creases in the latter during pregnancy, and after the stopp:ige 
 of menstruation. 
 
 Excretion. — The urine of women is usually lighter in 
 colour than that of men, and its specific gravity lower. 
 The amount of urinary solids is both absolutely and 
 relatively less than in the case of men, especially during 
 the reproductive era of her life. 
 
BIOLOGICAL CONSIDERATIONS. 
 
 663 
 
 ... 
 
 l 
 
 It is highly probable that those features which we call 
 secondary sexual characters, e.g. richer pigmentation, excess 
 of hairs and feathers, activity of scent glands, etc., which are 
 found in the males, are but the multiform expressions of the 
 katabolic predominance in the male organism. And it is 
 important to note that, in the great run of cases, these 
 characters are only fully developed as maturity is established. 
 In early life there is practically no physiological distinction 
 between the sexes. The establishment of the reproductive 
 functions is associated with the development of sexuol 
 features, which, as Darwin has pointed out, modify the 
 males to a much greater extent than the females throughout 
 almost the entire animal kingdom. " Generally," he states, 
 " the female retains a closer resemblance to the young of 
 her own species than to the adult members of the same 
 group." 
 
 Experimental evidence regarding the influence of various 
 conditions on the production of sex points abo strongly 
 towards the conclusion that " in the determination of sex, 
 influences inducing katabolism tend to result In the pro- 
 duction of males, as those favouring anabolism similarly 
 increase the probability of females " (Geddes and Thomson). 
 
 Poor or abnormal food, deficient light, moisture, excessive 
 lactation, and other conditions tending to diminish the 
 repair supply, or to cause a surplus of waste — the katabolic 
 habit, tend, in experiments made on lower animals, to the 
 production of males. Such tests strengthen the view that 
 the male is the index of a preponderating katabolism, and 
 the female of an equally marked anabolism. 
 
 Now, throughout the greater part of the animal kingdom, 
 this anabolic predominance in the female affords the means 
 of counteracting the katabolic influence of the part she has 
 to play in reproduction. 
 
 During the sexual life of females, among most of the 
 Primates, the anabolic habit does not find sufficient em- 
 ployment in supplying this destructive influence. An 
 
664 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 overplus exhibits itself in the production of milk during 
 the early period of the child's life, and, after lactation, in a 
 discharge of blood from the uterus. 
 
 Cases of menstruation during lactation might, by this 
 theory, be easily explained. The production of milk does 
 not use up the anabolic surplus, which, therefore, becomes 
 disposed of through the usual menstrual outlet. 
 
 In all mammalians below the Primates, the balance is 
 regulated without the occurrence of any loss through mens- 
 truation, reproduction, lactation, the care of the offspring, 
 and their moving habits apparently making such demands 
 upon the maternal anabolism, as that no surplus correspond- 
 ing to the menstrual blood of the human female is produced 
 by the system. t 
 
 (In the vegetable kingdom, also, it is interesting to note, 
 " the distinctly anabolic overflow of nectar ceases at fertilisa- 
 tion, and the surplus of continual preponderant anabolism 
 is grafted into the growing seed or fruit" — Geddes and 
 Thomson.) 
 
 One of the most striking characteristics of menstruation, 
 as observed in the human female, is its variability in type, 
 and in the quantity and duration of discharge. One need 
 not specify these in detail. I wish in particular to direct 
 attention to the great range of variation in the time of its 
 appearance in relation to the development of those other 
 phenomena which we call the " sexual characteristics." 
 
 In the majority of cases, these features, e.g. activity in 
 ovulation, menstruation, hair-development, growth of breasts, 
 etc., become established at a definite period, known as 
 puberty, which, as we know, varies according to climate, 
 race, environment, and other conditions. 
 
 But of far greater importance are the variations which 
 prove that there may be no concurrent incidence in the de- 
 termination of the phenomena in the individual. They are 
 as follows : — 
 
 I. Menstruation may begin very early in life, even within 
 
 n 
 
 i' 
 
 B 
 
 k ■ 
 
 r'- ■ 
 
 f ^ 
 
BIOLOGICAL CONSIDERATIONS. 
 
 665 
 
 the first year, without the development of any of the other 
 outward signs of puberty. These become marked, at vary- 
 ing periods in different cases, and in different orders. 
 Generally, they appear together after a number of years, but 
 sometimes the breast changes precede the others, some- 
 times the growth of hair, sometimes the changes in bodily 
 contour. 
 
 2. In other cases, the development of menstruation at a 
 very early period may be associated with one or more of 
 the other secondary sexual characteristics. 
 
 Thus the breasts may be well marked, or the external 
 genitals well developed, or the voice altered. The other 
 features appeared in later years. 
 
 3. In other cases, some of the secondary sexual character- 
 istics, other than menstruation, may be developed in very 
 early life, this function becoming established sooner or 
 later afterwards. Thus the breasts may become well 
 marked, menstruation following after months or years. In 
 a case recorded by Bouchut, in which the breasts were 
 well formed at birth, menstruation began at the age of 
 22 months, and the rest of the sexual features became 
 marked in the succeeding two years, so that at the age of 
 4 the child had all the characters of a fully - developed 
 girl. 
 
 Sometimes the breasts and external genitals may develop 
 early together. Sometinies the latter alone may be very 
 early marked, being followed sooner or later afterwards by 
 menstruation and the other phenomena. Sometimes the 
 breasts develop early along with axillary and pubic hairs, 
 being followed after months or years by menstruation. 
 Sometimes the body contour may resemble the adult 
 form, the hair and external genitals being well developed at 
 a very early period ; the appearance of menstruation, and 
 the growth of the breasts, being delayed for months or 
 years. 
 
 4. As regards the condition of the internal genitals, only 
 
666 
 
 THE EXPLANA TION OF MENSTRUA TION. 
 
 a few opportunities have presented themselves of observing 
 them in the above-cited cases, so that it is impossible to 
 know in how many ovulation was in progress, or the uterus 
 well developed. It is, however, clearly established that in 
 some of these precocious cases ovulation is in progress, and 
 the uterus has adult features. There can be no doubt, 
 therefore, that puberty may be completely developed in the 
 first years of life as regards the physical changes. As is to 
 be expected, the psychical alterations are wanting. 
 
 5. Finally, the cases must be alluded to in which, during 
 infancy and child life, ovulation has been noted, though 
 none of the other signs of puberty have been present. It 
 has been found in progress even before birth. In the great 
 majority of cases of normal development of puberty, it may 
 be in progress several months before the other phenomena 
 appear. In the adult state marked variations are found 
 as regards the degree to which the sexual characters are 
 developed. These need scarcely be specified, so commonly 
 are they observed by physicians. 
 
 They affect the breasts ; the pubic and axillary hairs ; 
 the formation of the external genitals ; the type, quantity, 
 and duration of the menstrual discharge ; the psychical 
 development. These differences exist between different 
 races and between the various members of the same race. 
 
 From the consideration of these facts, we are forced, it 
 seems to me, to regard the menstrual function as a highly 
 specialised means, gradually produced, in the evolution of 
 the highest mammals, by which the two great factors in 
 tissue-metabolism — the anabolic and katabolic, are properly 
 balanced. 
 
 Normally, it becomes established along with the various 
 phenomena which characterise the development of sexual 
 activity — at puberty, because it is then that the metabolic 
 habit peculiar to females, namely, predominance of ana- 
 bolism, manifests itself. 
 
 The rhythmical character of the menstrual function has 
 
 o ■ 
 
 n 
 
BIOLOGICAL CONSIDERATIONS. 
 
 667 
 
 probably been gradually determined by the forces of evolu- 
 tion, and the marked ran^e of variations which it presents 
 in the human female (unassociated with pathological con- 
 ditions) points very strongly to an early period of instability 
 in the process, preceding its present fairly fixed habit. It is, 
 indeed, impossible for us to think of a rational explanation 
 for the peculiarities which are found, except on the ground 
 of biological variations — atavistic reminiscences. 
 
 The menstrual function, then, being closely correlated 
 with the well-recognised sexual characters, is, like them, 
 undoubtedly closely related to a nervous regulating 
 mechanism, the nature of which is unknown as yet. 
 
 There may be a special cord centre governed by still 
 higher cortical centres, but there is also a subtle and 
 intimate connection between the sexual functions and 
 the general nervous mechanism of the body. 
 
 As Johnstone ably states in regard to the uterus, " its 
 association with ovarian activity is that of two separate 
 departments of an army, each of whose work must be 
 thoroughly accomplished before the one common object 
 can be attained. They are both controlled by branches 
 from the sympathetic system, and instead of their actions 
 being determined by each other, their orders come fro .n that 
 higher power which controls all functional activity. 
 
 It is this correlation which has been wrongly interpreted, 
 especially in the case of the tubal and ovarian functions, 
 with neither of which is the process directly connected. 
 That it is indirectly related to them, and capable of being 
 influenced by them, cannot be denied, and that, in the 
 whole sexual apparatus, the ovaries are the " predominant 
 partner," is not to be wondered at. 
 
 We have proof enough as regards their influence on body- 
 metabolism, e.g. in osteomalacia, marked improvement imme- 
 diately follows removal of the ovaries. Whether this be 
 due, as Curatulo believes, to the secretion by these organs 
 of a chemical substance capable of facilitating the oxida- 
 
668 THE EXPLANATION OF MENSTRUATION. 
 
 . ■ „ \ \ 
 
 tion of the phosphoric organic substances supplying material 
 for the bone salts, or whether it acts merely by altering an 
 ill-proportioned relationship between anabolic and katabolic 
 functions, thus secondarily affecting the diseased process, is 
 only a matter of speculation. 
 
 After the removal of the ovaries in gynecological practice, 
 certain effects are noted which must be associated with 
 altered neurotrophic functions. Thus " heats " or " flushes " 
 — vasomotor storms — are very often troublesome features ; 
 the uterus tends to shrink ; the gland tissue of the breasts 
 tends to atrophy, wnile fat is often increased in the body. 
 
 There is, however, very great variation as regards the 
 effect of removal on the sexual characters. These are so 
 marked as to demand a careful investigation for the purpose 
 of determining them accurately, and of establishing a com- 
 parison between the bodily changes following the operation, 
 and those taking place in connection with the normal 
 climacteric. At present many exaggerated ideas are 
 current. 
 
 While, in the majority of cases, removal of the ovaries 
 is followed by an altered body-metabolism, owing to the 
 absence of the most important sexual organ — marked by 
 disappearance of the anabolic overflow of menstruation, it is 
 not surprising that variations should occur in the altera- 
 tions produced, so that instances might happen in which the 
 menstrual function does not cease. It is certainly not an 
 uncommon experience to find discharges of blood from the 
 uterus after the operation, apparently an indication that the 
 changes in body-metabolism are being brought about but 
 gradually in these cases. 
 
 As regards the relation of the tubes to menstruation, if 
 Lawson Tait's observations be accurate, namely, that after 
 their removal menstruation ceases in the great majority of 
 cases, the ovaries being left behind, the explanation may be 
 either that such a marked alteration in the genital tract 
 may reflexly alter all the sexual functions along with body- 
 
BIOLOGICAL CONSIDERATIONS, 
 
 669 
 
 metabolism, or that it may bring about the result through 
 an indirect influence (such as inhibition of function) on the 
 ovaries. 
 
 (Bland Sutton's statements as regards the effects of 
 removal of the tubes are directly opposed to those of 
 Lawson Tait. His words are : " The Fallopian tubes exer- 
 cise no influence on menstruation, and in order to produce 
 artificial amenorrhoea both ovaries must be completely 
 removed." I do not consider that Bland Sutton is justified 
 in making these statements from the facts given by him. 
 He quotes a few cases in which ligature of the tubes was 
 performed without causing a cessation of menstruation. 
 Tait, however, speaks of removal of the tubes, — a much 
 more serious disturbance.) 
 
 Though there can be little doubt that menstruation has 
 been established in the higher mammals by a gradual pro- 
 cess of evolution, we have been entirely in the dark as to 
 the steps of this process. Seeing that it is limited to the 
 Atithropidce and Simiadcs, the earliest appearance must have 
 taken place among some common ancestors of both. 
 
 The peculiarity probably first began as a variation, which 
 proved to be advantageous, and by natural selection became 
 a fixed character, being transmitted from generation to 
 generation. Had it been of no advantage it would have 
 been eliminated. 
 
 The only suggestion which has yet been advanced as to 
 the possible advantage of this variation is that of W. E. 
 Fothergill, who believes that it consisted in a greater tend- 
 ency to conception, owing to the rawing of the uterine 
 mucosa. 
 
 This suggestion cannot be entertained in the light of 
 present knowledge. We know that rawing of the surface is 
 not necessary to the attachment and nidation of the fertilised 
 ovum, and that in the great mass of the mammals it does 
 not occur. 
 
 The introduction of menstruation in the evolution of the 
 
670 THE EXPLANATION OF MENSTRUATION. 
 
 mammalians has not been associated with greater but with 
 diminished fertility, for there can be no doubt that the non- 
 menstruating mammals are on the whole by far the most 
 prolific. 
 
 Indeed, natural selection has acted in the highest ranks 
 of the animal world, not in the direction of establishing a 
 numerical superiority, but one based on the specialisation of 
 individual characteristics in a selected number. 
 
 The advantage of the variation in our distant progenitors 
 must therefore be sought for in relation to factors tending 
 to diminish the number of offspring, and to improve the 
 quality of the individual. 
 
 As to the origin of the variation, our only reasonable 
 speculation seems to be that it is associated with the 
 development of the single uterus, with the diminution in 
 the number of offspring, with the determination of the 
 semi-erect or erect posture — characteristics found through- 
 out the Primates, at least in the Simiadce or Anthropidce. 
 (The division of the Primates known as LemuridcB stands 
 by itself. These forms are believed not to be in the 
 direct line of the other divisions, but a separate off- 
 shoot from some early common mammalian stock. They 
 have a double uterus, and, so far as we know, do not 
 menstruate.) 
 
 Of prime importance, I believe, among these factors 
 is the change from the bicornuate to the single condition 
 of uterus. In the great mass of mammals with the former 
 variety, the excess of anabolism is used up in the large 
 demands of breeding and nursing. When the single uterus 
 appeared as a variation, marked by a diminished area for 
 the attachment of ova, the unused anabolism found an 
 outlet in the escape of blood. 
 
 It is possible that this took place at first from different 
 parts of the body, thus helping to explain the occasional 
 occurrence in females of "vicarious menstruation." 
 
 If this were the case, natural selection must have acted 
 
 t 
 
 f\ 
 
BIOLOGICAL CONSIDERATIONS. 
 
 671 
 
 *;■??:■. 
 
 in eliminating all except those in whom the blood escaped 
 from the uterus. 
 
 But it is also likely that the tendency to sit on the 
 ischial tuberosities and to move about more or less in the 
 semi-erect position, may have somewhat determined the 
 occurrence of the congestion chiefly in the pelvis, relief 
 being found by a discharge from the delicate mucosa. 
 
 The blending of two blood supplies in a single uterus, 
 which had previously been distributed to two cornua, must 
 have had an influence in inducing a special tendency to 
 uterine congestion. Probably also another factor helped to 
 determine the localisation of the congestion to the pelvis, 
 namely, the habit already fixed among many of the lower 
 mammals of the periodic pelvic congestion of the rutting 
 period. 
 
 In the beginning it is likely that the menstrual discharge 
 took place at irregular intervals (thus explaining the occa- 
 sional irregular types which are now found among females). 
 Natural selection would here come into play in determining 
 regularity of type. 
 
 Females who were irregular in regard to the discharge 
 would be objects of inconvenience to the males, who would 
 very soon learn to seek out and prefer those whose unseem- 
 liness manifested itself only at expected and definite periods ; 
 and so, gradually, regularity v/ould come to be the predom- 
 inant feature in succeeding generations of offspring. 
 
 It is a striking fact that among all races there is a careful 
 avoidance of menstruating females by the males. This 
 is particularly marked in most primitive peoples. Very 
 possibly it had its origin in a feeling of disgust on the 
 part of the males, and it is not difficult to understand how, 
 among the earliest human beings, there might gradually 
 develop the belief that women were possessed of some 
 unclean or evil spirit which had to escape periodically. 
 
 It is thus easy to explain the universal though varied 
 customs and practices prevalent in many races, by which 
 
672 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 the woman is forced at her period to avoid association with 
 others, to abstain from coitus with men, and to withdraw 
 even from observation, in order that her evil influence might 
 not spread. 
 
 Next, it is of great interest to inquire into the possible 
 gains that might result from the fixing of menstrual process 
 in females. 
 
 It is a remarkable fact that in the highest mammals, 
 namely, the Simiadce and AnthropidcB, is found the highest 
 development of the altruistic principle, as exhibited between 
 parents and offspring. As Westermarck points out, among 
 the Invertebrata the male is interested only in the act of 
 fertilisation, while the female shows no further concern 
 or responsibility after she has laid her eggs. In the lower 
 Vertebrata parental care is almost unknown, though there 
 are a few exceptions, e.g. chiefly in the Chelonia, the 
 males caring for the young in some cases, the females in 
 others, while in a few instances there is joint parental 
 attention. 
 
 In the Birds, however, it is the rule that the parents 
 live in most intimate relationships, both during and after 
 the breeding-season, the female hatching and rearing, the 
 male acting as protector and provider of food. 
 
 Among the great mass of mammalians, below the Primates, 
 this is not the case ; the mothers alone showing great con- 
 cern for the young offspring, while generally the males are 
 only interested in the females at the rutting-time. 
 
 Exceptions are, however, found, e.g. among whales, seals, 
 certain deer, moles, squirrels, and a few other forms. The 
 parents remain together after the birth of the young, the 
 male acting as protector. 
 
 Among the Primates the rule is that the males and 
 females unite in a more or less enduring partnership, both 
 having great concern for the care of the offspring, the males 
 possessing one or more wives. 
 
 There is an abundance of facts to establish this statement. 
 
 I' 
 
 ?# 
 
 ! 
 
 i 
 
 IV 
 
BIOLOGICAL CONSIDERATIONS. 
 
 •73 
 
 and from them VVestermarck has rstablished his induc- 
 tion in a masterly work, that our human marriage is an 
 inheritance from an ape-like ancestor, controverting the 
 long-held belief of Sir John Lubbock and others, that our 
 progenitors formed one vast free-love community where 
 promiscuity of sexual intercourse prevailed. 
 
 This habit is therefore another interesting ix)ssession of 
 mammals with a sirigle uterus. It marks a great advance 
 in the character of the individual above the ty[Xis found 
 in the lower orders of animal life. 
 
 Very evidently it was fostered by means of natural selec- 
 tion, being most essential whf "i the female gave birth to 
 a small number of young who ^^assed a long time in a 
 state of helpless infancy and tutelage. Such a species, 
 undoubtedly, stands a better chance of surviving when the 
 parents unite their energies in the task of protecting and 
 nurturing the offspring. 
 
 Indeed, it would appear that the great determining 
 factor of conjugal relationships is care for the young. 
 Among several primitive races (and in some of the highest) 
 marriage is never supposed to be established until offspring 
 appear. 
 
 Wherever in the animal kingdom we find that the 
 parents have no concern for the. offspring, the females give 
 birth to a very large number of young, the prodigality of 
 births allowing of the safeguarding of the preservation of the 
 species. 
 
 Thus the cod lays each year about a million eggs, to 
 which she gives no after-care, and probably the greater 
 number become destroyed. On the other hand, the turtle- 
 dove lays only two eggs, but owing to the care of the 
 parents, the young generally grow to maturity. 
 
 Another important point to notice regarding intercourse 
 
 between the sexes is that while among the majority of 
 
 mammals there are special times of pairing, conditioned 
 
 by divers necessities, varying in different species, among the 
 
 43 
 
674 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 Quadrumana the rule is, probably, that fruitful intercourse 
 may take place at any time, though undoubtedly exceptions 
 occur, owing to conditions of food, environment, etc. 
 
 In the evolution, therefore, of the higher mammals pos- 
 sessing one uterus there has been a departure from the 
 condition of periodic excesses of sexual rioting to one 
 in which there is, especially in the female, a more diffuse 
 and consequently less intense manifestation of the sex 
 instinct. 
 
 The menstrual function occurring regularly in animals so 
 placed must have served beneficially in giving the mothers 
 continually recurring periods of ensured rest (for, so far as we 
 know, coitus is universally desisted from during menstrua- 
 tion), and in teaching the males continual lessons in self- 
 restraini. \ 
 
 Relation of Menstruation to Rut. 
 
 There is a widespread belief that these phenomena are 
 identical. Thus a very recent writer (Letourneau) states that 
 " menstruation is essentially identical with the intimate 
 phenomena of rut in the females of mammals, and corre- 
 sponds to an ovarian congestion, or to the swelling and burst- 
 ing of one or more Graafian follicles." A few writers have in 
 recent years disputed this view, among whom may be chiefly 
 mentioned Lawson Tait. 
 
 There are many who believe that the rut, or oestrus, or 
 pairing-time is conditioned by ovulation^ — that ova are only 
 shed at these intervals, causing the phenomena. There is 
 no basis of facts for this statement. The examination of 
 many rutting animals proves that ovulation goes on at all 
 times. The origin and significance of rut are uncertain, but 
 it seems probable that the habit has been developed by 
 natural selection, for the purpose of limiting the chance of 
 fertilisation to certain seasons, mainly with reference to 
 dietetic and climatic requirements for the offspring. 
 
 ■i; 
 f 
 
 4 
 
 f V 
 
K ELATION OF MENSTRUATION 70 KUT. 
 
 675 
 
 to 
 
 Among the mammalians this period is found at all times 
 of the year. Thus, the bat pairs in January and February ; 
 the wild cat and fox in February ; the weasel in March ; the 
 musk-ox in August ; the badger in October ; the orongo- 
 antelope in November and December. 
 
 When the different cases are inquired into, it will be found 
 that the time of pairing is related to the duration of preg- 
 nancy, it being necessary that the young should be born at 
 a time when they stand the best chance of living. 
 
 Thus the majority of mammals produce offspring early in 
 the year ; in the tropics at the beginning of the rainy season 
 — the time of birth evidently being related to abundance of 
 food, water, warmth of climate, conditions most favourable 
 to existence. In polar and temperate regions the animals 
 pair at a later period than in warm countries. These differ- 
 ences are seen when the same species are placed under 
 changed climatic conditions. 
 
 When no definite pairing-season exists, as among elephants, 
 whales, many rodents, the explanation is very evident. The 
 conditions of their environment and of their food-supply are 
 such as not to necessitate the birth of offspring at special 
 times. 
 
 As regards the Primates, it is doubtful if there is a rutting 
 season among many species. It is stated by some observers 
 that it exists in the orang-utan and gorilla. In general it is 
 to be expected that in the SimiadcB and Anthropidce, whose 
 food-supply is of a much more diverse nature than in the 
 lower mammalians, consisting of animal and vegetable 
 matter in different forms, there is no necessity for the birth 
 of offspring at special times. Moreover, it must be remem- 
 bered that the anxious time as regards the newly-born does 
 not last only for a few months after birth in the Si/niadce, 
 but for years, the period of infancy being long, just as in the 
 case of Homo. It is therefore likely that, as far as food re- 
 quirements are concerned, one season is as propitious as 
 another for birth. 
 
 i 
 
 j 'I 
 
 ^■1 
 
 1^ 
 
676 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 Another important factor must be borne in mind, namely, 
 that where there is a strong development of parental affec- 
 tion, and conjoint parental care for the young, an important 
 additional reason exists for diminishing the necessity of 
 special pairing-seasons. This is all the more marked in the 
 Anthropidce^ where, owing to a higher intelligence, individuals 
 learn to combat the injurious influences of their environment 
 and to make it possible for the offspring to have as good a 
 chance of surviving at one time of the year as at another. 
 
 If, then, there be found exceptional cases of a special 
 pairing-season among the higher Primates, it must be 
 because natural selection has conserved the habit in relation 
 to the special conditions in which those species are placed. 
 
 Among the Reptilians and Birds, the rule is that pairing 
 occurs in the spring; and it is probable that, as Westermarck 
 points out, the world-wide association of the spring-time with 
 the awakening of sexual affinities has been based upon the 
 observations made mainly on birds. 
 
 The modifications in the pairing-season which can be 
 induced by artificial means, e.g. domestication, are a strong 
 evidence in favour of the bearing of external influences on 
 reproduction among the higher Vertebrata. 
 
 Indeed, it is evident that just as rut becomes adapted to 
 the requirements of separate species, so it may become 
 altered in relation to the needs of individuals under varying 
 conditions. 
 
 Another interesting fact must be mentioned, namely, that 
 while the rutting period is practically the only time when 
 the females will copulate with the males, the menstrual 
 period is the time above all other periods when they will 
 not engage in this act. This is universal among mankind, 
 and is true for the Simiadte, as far as our observations go. 
 
 Moreover, the changes in connection with rut result among 
 other things in softening and dilating the outer genitals for 
 the reception of the penis, they being at other times in many 
 animals too much constricted for this. It is well knov/n 
 
ii 
 
 RELATION OF MENSTRUATION TO RUT. ffn 
 
 that a bitch will not generally allow the dog near her until 
 the rut has been in progress for a time, i.e. until the vulva 
 and vagina are sufficiently dilated. 
 
 So far as our facts go, it seems likely that rut in the 
 higher Vertebrates is merely the expression of the force of 
 sexual affinity necessary to ensure fertilisation of the ovum, 
 which is found throughout the whole animal kingdom, 
 diffusely spread in the lower forms, highly specialised and 
 limited in the upper forms, owing to the influences of en- 
 vironment and natural selection, and affecting both males ana 
 females alike. This participation of the males is important to 
 bear in mind. It is found everywhere. Thus many fishes, 
 when the love period arrives, put on brilliant colours, become 
 vigorous and play about among the females in the most 
 lively fashion — evidently in a state of sexual excitement. 
 In some, e.g. the stickleback and salmon, great pugnacity 
 is manifest. The male salmon develops a special crook in 
 connection with the lower jaw at this time, while the teeth 
 enlarge markedly. Among many Amphibians also various 
 changes affect the males, and sexual desire becomes very 
 marked. Among the Reptilia similar changes occur, the 
 male tortoise, for example, being fierce and noisy. 
 
 In snakes the scent glands become active during the 
 pairing-season. 
 
 Among the birds, the changes in the love season are very 
 marked. The male is altered in various wayii, and takes to 
 dancing, coquetting, and to vocal and instrumental music. 
 His scent glands grow active, his ornaments become more 
 marked, and he develops strong fighting tendencies. 
 
 Among mammals the intensification of sexual desire in 
 the males, accompanied with a feeling of jealousy and a 
 keenness to fight, is universal. In all orders the voice is 
 used in the rutting-time more than at any other season. 
 Indeed, the porcupine and giraffe are said to be mute at 
 all other periods. 
 
 In stags the larynx and thyroid enlarge when rut comes 
 
678 
 
 THE EXPLANATION OF MENSTRUATION. 
 
 on. The nose of the male sea-elephant becomes greatly 
 elongated. In the bladder - nose seal the hood covering 
 the head becomes markedly inflated. Scent glands emit 
 stronger odours. In some cases the colour of the skin 
 changes. 
 
 Among the great majority of females, no such marked 
 variations occur. They play their normal role of passivity, 
 the alterations brought about by the wave of sexual excite- 
 ment being mainly psychical. 
 
 In many mammalians the only physical changes recognis- 
 able at the oestrus are congestion of the soft parts in the 
 pelvis, dilatation of the vulva and the vagina, and the free 
 discharge of mucus, which is often blood stained. These 
 differences between males and females in regard to the 
 rutting period are in keeping with the organic distinction 
 to which I have so often referred in these pages. 
 
 The manifold changes in the males are the outcome of 
 their predominant katabolism. 
 
 The fe? lales need to conserve their energies, i.e. their 
 anabolic surplus, for the strain of pregnancy, consequently 
 there is no waste in outward exuberant manifestations, 
 except in very slight measure in the cases to which I have 
 just alluded. 
 
 Finally, it may be stated that the relation of rut to mens- 
 truation in mammalian evolution is simply this — that when, 
 owing to the different reasons which I have elaborated in an 
 earlier part of this chapter, menstruation appeared as a new 
 variation, one of the factors in determining the escape of the 
 anabolic overplus by way of the genital tract was the habit 
 already fixed, in many of the mammalians with a bicornuate 
 uterus, of the periodic yearly pelvic congestion of the rutting- 
 time. 
 
I N D F, X. 
 
 A. 
 
 
 
 
 PAGE 
 
 
 
 PACE 
 
 Abdomen, auscultation of 
 
 175 
 
 Antiseptics 
 
 ., cleansing of instru- 
 
 
 ,, inspection of 
 
 173 
 
 
 ment s, 
 
 
 ,, mensuration of 
 
 175 
 
 
 apparatus, 
 
 
 „ palpation of 
 
 174 
 
 
 etc. 
 
 246 
 
 „ percussion of 
 
 174 
 
 )i 
 
 ,, of operator, 
 
 
 Abdominal section in general 
 
 270 
 
 
 assistants, 
 
 
 ,, ,, after -com- 
 
 
 
 and nurses 
 
 245 
 
 plications 
 
 289 
 
 >» 
 
 „ of patient . 
 
 249 
 
 ,, ,, after-treat- 
 
 
 Apparatus 
 
 • • • • 
 
 258 
 
 ment 
 
 284 
 
 Arteries of 
 
 pelvis . 
 
 49 
 
 „ ,, closure of 
 
 
 Asepsis and antiseptics . 
 
 244 
 
 abdominal 
 
 
 Aspirator 
 
 • • • • 
 
 214 
 
 wound 
 
 276 
 
 Atresia of 
 
 cervix . . 416, 
 
 436 
 
 ,, ,, opening into 
 
 
 ,, of 
 
 hymen . 
 
 592 
 
 peritoneum 
 
 272 
 
 ,, of 
 
 septate uterus 
 
 414 
 
 ,, ,, preparation 
 
 
 ,, of 
 
 vagina . 
 
 590 
 
 of patient 
 
 270 
 
 
 
 
 Abscess, pelvic 
 
 326 
 
 Bacteriology of pelvic viscera 
 
 
 Adhesions, peritonitic . 
 
 315 
 
 
 in normal 
 
 
 Alquie - Alexander - Adams 
 
 
 
 condition 
 
 146 
 
 operation .... 
 
 459 
 
 >> 
 
 ..during 
 
 
 Amenorrhoea 
 
 117 
 
 
 mnstru- 
 
 
 Amputation of cervix, circular 
 
 439 
 
 
 ation 
 
 147 
 
 ,, ,, Martin's 
 
 439 
 
 >» 
 
 in abortion 
 
 148 
 
 ,r ,, Schroe- 
 
 
 »» 
 
 in girls and women 146 
 
 der's 
 
 432 
 
 >> 
 
 in intestinal tract 
 
 150 
 
 „ of uterus in in- 
 
 
 u 
 
 in new-ljorn child 
 
 146 
 
 version . 
 
 468 
 
 M 
 
 in pregnancy 
 
 148 
 
 ,, ,, in fibroids. 
 
 48s 
 
 )» 
 
 in puerperium . 
 
 148 
 
 Anteflexion of uterus 
 
 447 
 
 »» 
 
 in urethra 
 
 148 
 
 Anteversion ,, 
 
 445 
 
 Bandages, 
 
 abdominal . 
 
 229 
 
 Antiseptics .... 
 
 253 
 
 Bartholinian glands, abscess in 
 
 545 
 
 ,, chemical 
 
 253 
 
 >» 
 
 ,, anatomy of . 
 
 47 
 
 ,, cleansing of air and 
 
 
 »» 
 
 „ cysts of 
 
 47 
 
 contents 
 
 
 »> 
 
 ,, inflammation 
 
 
 of room 
 
 252 
 
 
 of . 
 
 545 
 
68o INDEX. 
 
 <.»••> 
 
 \ . 
 
 >> 
 
 >> 
 )> 
 
 »> 
 
 >» 
 >» 
 
 M 
 1> 
 >> 
 >» 
 
 >> 
 
 > > 
 >> 
 
 Baths, the use of . 
 
 Bimanual examination, . 178 
 
 Bladder, absence of 
 
 affecticns of . 
 anatomy of 
 calculus . 
 
 cyst of the urachus . 
 cystocele . 575, 
 displacements 
 double . 
 epispadias 
 extroversion . 
 foreign bodies 
 inflammation . 
 necrosis . 
 neoplasms 
 prolapse of mucosa . 
 rupture . 
 tuberculosis . 
 Blood effusion into pelvis 
 ,, „ ,, peritoneal 
 
 cavity . 
 „ „ ,, ovarian 
 
 tumours 
 „ ,, „ vulva 
 
 ,, vessels of pelvis . 
 Brandt's pelvic massage 
 Broad ligament, anatomy of 
 ,, cysts of 
 
 ,, htemorihage 
 
 in 
 ,, new growths 
 
 in 
 Bulbs of the vagina 
 
 Case-taking . 
 
 anamnesis 
 physical examina 
 tion 
 Cautery, electric 
 ,, thermo- 
 Cellulitis, pelvic 
 Cervix, amputation . 432 
 ,, atresia 
 ,, carcinoma 
 ,, dilatation 
 ,, erosion of 
 ,, excision 
 ,, fibroids 
 
 ,, hypertrophic elonga 
 ' tion 
 
 
 PAGE 
 
 224 
 
 , 181 
 
 608 
 
 606 
 
 57 
 614 
 608 
 , 608 
 608 
 608 
 606 
 606 
 619 
 609 
 
 613 
 616 
 608 
 620 
 612 
 329 
 
 329 
 
 387 
 550 
 
 49 
 228 
 
 71 
 344 
 
 342 
 
 344 
 46 
 
 160 
 163 
 
 172 
 229 
 228 
 321 
 
 439 
 436 
 505 
 434 
 420 
 
 435 
 476 
 
 437 
 
 :J- 
 
 Cervix, incision ". 
 
 ,, incomplete removal 
 
 of cancer of 
 ,, laceration . 
 , , sarcoma 
 ,, stenosis 
 Climacteric . 
 
 ,, delayed 
 
 ,, early . 
 
 ,, general phenomena 
 
 ,, relation to special 
 
 diseases . 
 ,, structural changes . 
 Coccydynia .... 
 Coitus, questions regarding . 
 Colpitis, 5y/«fe " Vaginitis " 
 Connective tissue of pelvis, 
 affections of 
 ,, ,, cysts of broad 
 
 ligament . 
 ,, ,, haematoma . 
 
 ,, ,, hydrocele of 
 
 round liga- 
 ment . 
 ,, ,, inflammation 
 
 ,, ,, retroperitoneal 
 
 tumours 
 
 ,, ,, solid tumours 
 
 of broad 
 
 ligament 
 
 ,, ,, various other 
 
 tumours 
 
 Colpoperineorrhaphy 
 
 Colporrhaphy 
 
 Colpotomy, vide ''Vaginal 
 
 Section " . 
 Corpus luteum 
 Curette 
 Curetting 
 Cystitis 
 Cystocele 
 Cystoscope, electric 
 
 Dermoid tumours of ovary 
 Dilatation of uterus 
 „ vagina 
 
 Dilators 
 
 Displacement of uterus 
 Douching, uterine . 
 vaginal 
 
 PACE 
 
 435 
 
 5-0 
 
 441 
 
 529 
 
 433 
 109 
 
 117 
 116 
 112 
 
 "5 
 III 
 
 650 
 
 169 
 
 581 
 
 321 
 
 344 
 342 
 
 345 
 321 
 
 345 
 
 344 
 
 345 
 579 
 578 
 
 295 
 7 
 210 
 211 
 609 
 
 575 
 187 
 
 378 
 205 
 203 
 203 
 
 445 
 221 
 216 
 

 
 INDEX. 
 
 
 
 681 
 
 
 
 PAGE 
 
 
 
 
 PACK 
 
 Drainage of peritoneum 268, 
 
 278 
 
 Fallopian tubes, 
 
 comparative 
 
 
 ,, of wounds 
 
 268 
 
 ■ c ,. ■■ ■■' ' 
 
 
 notes . 
 
 14 
 
 Dressings 
 
 . 
 
 249 
 
 At 
 
 
 development 
 
 12 
 
 Dysmenorr 
 
 la'a 
 
 121 
 
 »» 
 
 
 hnjmorrhage 
 
 
 Dysp)areunia 
 
 169 
 
 
 
 into tube . 
 
 361 
 
 Dysuria 
 
 • * t • 
 
 638 
 
 »t 
 
 
 hydrosalpinx 
 
 349 
 
 • . 
 
 .% 
 
 
 It 
 
 
 inflammation 
 isthmus 
 
 347 
 10 
 
 Ectropium 
 
 of cervix 
 
 420 
 
 *l 
 
 
 new growths 
 
 36s 
 
 Electricity 
 
 • • • • 
 
 237 
 
 l» 
 
 
 pavilion 
 
 10 
 
 i> 
 
 apparatus 
 
 238 
 
 it 
 
 
 physiological 
 
 
 >» 
 
 conditions in which 
 
 
 
 
 note . 
 
 13 
 
 
 used 
 
 240 
 
 tt 
 
 
 position 
 
 9 
 
 '■♦. 
 
 contra-indications 
 
 
 it 
 
 
 pyosalpinx . 
 
 350 
 
 
 and dangers 
 
 242 
 
 »i 
 
 
 stricture and 
 
 
 1* »• 
 
 faradic . 
 
 239 
 
 
 
 occlusion . 
 
 347 
 
 >> 
 
 galvanic 
 
 239 
 
 II 
 
 
 structure 
 
 II 
 
 Emmet's operation 
 
 443 
 
 II 
 
 
 tuberculosis . 
 
 363 
 
 Endocervicitis 
 
 419 
 
 Fibroids, panhysterectomy for 
 
 491 
 
 Endometri 
 
 s . . . 
 
 422 
 
 Fibromyoma 
 
 of uterus, calcifi- 
 
 
 i> 
 
 fungosa . 
 
 424 
 
 
 
 cation 
 
 472 
 
 >j 
 
 glandular 
 
 423 
 
 ) 1 
 
 II 
 
 changes in . 
 
 472 
 
 >> 
 
 hemorrhagic . 
 
 424 
 
 II 
 
 II 
 
 curettage . 
 
 483 
 
 >> 
 
 interstitial 
 
 423 
 
 II 
 
 II 
 
 dilatation of 
 
 
 >> 
 
 mixed 
 
 423 
 
 
 
 cervix 
 
 483 
 
 Enterocele 
 
 vaginal 
 
 576 
 
 II 
 
 II 
 
 electric treat- 
 
 
 Epispadias 
 
 . 602 
 
 ,606 
 
 
 
 ment of . 
 
 482 
 
 External genitals, anatomy of 
 
 40 
 
 II 
 
 II 
 
 enucleation 
 
 
 >> 
 
 clitoris 
 
 43 
 
 
 
 of inter- 
 
 
 *t 
 
 corpus cav- 
 
 
 
 
 stitial tu- 
 
 
 
 ernosum . 
 
 46 
 
 
 
 mours 
 
 484 
 
 >» 
 
 development 
 
 64 
 
 II 
 
 »i 
 
 etiology of . 
 
 476 
 
 ft 
 
 examination 
 
 
 ji 
 
 11 
 
 extraperiton- 
 
 
 
 of . 
 
 176 
 
 
 
 eal 
 
 489 
 
 n 
 
 fourchette . 
 
 41 
 
 11 
 
 1 1 
 
 jangrene . 
 
 472 
 
 >i 
 
 labia majora 
 
 41 
 
 II 
 
 1) 
 
 lardening . 
 
 472 
 
 »t 
 
 ,, minora 
 
 42 
 
 I > 
 
 II 
 
 inflammation 
 
 472 
 
 '■ »• 
 
 mons veneris 
 
 40 
 
 1) 
 
 II 
 
 interstitial . 
 
 474 
 
 >• 
 
 nerve-ending 
 
 s 52 
 
 II 
 
 II 
 
 intra pe r i- 
 
 
 »» 
 
 vestibule . 
 
 45 
 
 II 
 
 II 
 
 toneal 
 ligation of 
 uterine 
 
 48s 
 
 Fallopian 1 
 
 ubes, actinomycosis 
 
 365 
 
 
 
 arteries . 
 
 483 
 
 j> 
 
 affections of. 
 
 347 
 
 II 
 
 11 
 
 major surgi- 
 
 
 li 
 
 ampulla 
 
 10 
 
 
 
 cal I ro- 
 
 
 t> 
 
 anatomy of . 
 
 9 
 
 
 
 cedures . 
 
 483 
 
 If 
 
 anomalies 
 
 
 ) 1 
 
 II 
 
 medical treat- 
 
 
 *- 
 
 of posi- 
 
 
 
 
 ment of . 
 
 481 
 
 
 tion . 
 
 347 
 
 i> 
 
 >i 
 
 minor surgi- 
 
 
 »» 
 
 ,, of struc- 
 ture 
 
 347 
 
 
 
 cal pro- 
 cedures. . 
 
 483 
 
v. 
 
 682 
 
 INDEX. 
 
 ) \ 
 
 Fihromyoma 
 
 of uterus, panhy- 
 
 
 
 sterec- 
 
 .... 
 
 
 tomy . 
 
 H • 
 
 )> 
 
 pathology of 
 
 '■'' »»' 
 
 >» 
 
 physical signs 
 of . 
 
 ■■■-;'■ %% 
 
 ji 
 
 removal of 
 
 K':'r • . ■ 
 
 
 append- 
 ages 
 
 07 - .», 
 
 M 
 
 ,, cervical 
 tumours . 
 
 •M ,, ^ 
 
 »> 
 
 ,, intraliga- 
 
 '■*'■) 
 
 
 mentous 
 
 \ »• 
 
 
 tumours . 
 
 >» 
 
 ,, submucous 
 
 
 
 tumours . 
 
 »l ' 
 
 >) 
 
 ,, subperi- 
 toneal tu- 
 mours . 
 
 '>'»• 
 
 ■ 1 
 
 sarcoma 
 
 ^^ » 
 
 )> 
 
 softening . 
 
 ■ M' 
 
 l> 
 
 submucous . 
 
 ■•»»■■ 
 
 >> 
 
 subperiton- 
 eal . 
 
 >» 
 
 >1 
 
 suppuration 
 
 »»■ 
 
 l» 
 
 supravaginal 
 hysterec- 
 tomy 
 
 »* 
 
 l> 
 
 surgical treat- 
 
 / 
 
 
 ment of . 
 
 • *» ■ 
 
 11 
 
 symptoms 
 
 of . 
 varieties 
 
 Gartner's canals . 
 
 Genital tract in relation to 
 
 micro-organisms 
 Genito-urinary fistula 
 
 ,, incurable . 
 „ large 
 ,, s m a 1 1 or 
 medium . 
 ,, uretero- cer- 
 vical 
 „ ,, vaginal 
 „ ur eth ro- 
 vaginal . 
 ,, utero-vcsical 
 ,, ,, vesical - 
 vaginal 
 ,, very large . 
 
 M 
 it 
 tt 
 
 »» 
 
 i» 
 it 
 
 >» 
 it 
 
 It 
 
 I'AGE 
 
 491 
 472 
 
 479 
 
 485 
 499 
 
 492 
 494 
 
 483 
 472 
 472 
 
 475 
 
 473 
 472 
 
 485 
 
 483 
 
 477 
 473 
 
 15 
 
 146 
 621 
 
 63s 
 628 
 
 62s 
 
 635 
 634 
 
 634 
 633 
 
 632 
 631 
 
 I'AGR 
 
 Genito-urinary fistula, very 
 
 small 62 
 Genu-pcctoral posture . . 9; 
 
 Gonococcus 
 Gonorrhoea . 
 Gonorrhoeal vaginitis 
 Graafian follicle . 
 
 153 
 153 
 
 582 
 
 3 
 
 329 
 
 Hsematocele .... 
 Hsematokolpos, viefe "Atresia 
 
 of the Vagina " . . . 590 
 
 Hcematoma .... 340 
 
 Hccmatosalpinx . . . 361 
 
 Hermaphroditism . . 8, 543 
 
 Hydrops foliiculorum . . 372 
 
 Hydrosalpinx . . . 349 
 
 Hymen, abnormalities of . 600 
 
 , , anatomy of . -37 
 
 , , atresia of . . 592 
 
 ,, comparative note . 40 
 
 , , cysts of . . . 600 
 
 ,, development of . 40 
 
 ,, forms of . . -38 
 
 ,, infantile ... 39 
 
 Hypospadias . . . 603 
 
 Hysterectomy, abdominal . 485 
 
 „ vaginal . . SH 
 
 Hysteria . . . '137 
 
 Injections, uterine 
 ,, vaginal 
 
 Insanity in relation to pelvic 
 
 diseases 
 Intestinal obstruction after ab 
 
 dominal section . 
 Intra-abdominal pressure 
 Inversion of uterus 
 Irrigation of peritoneum 
 
 Kolpokleisis . 
 Kraurosis vulvee 
 
 t ■( 
 
 Labia majora, anatomy of 
 ,, ,, hydrocele 
 
 ,, minora, anatomy of 
 
 Leucorrhoea . 
 
 Levator ani . 
 
 Ligatures 
 
 Lymphatics of pelvis 
 
 221 
 216 
 
 140 
 
 293 
 
 97 
 
 463 
 
 274 
 
 635 
 550 
 
 41 
 
 345 
 
 42 
 
 168 
 81 
 
 254 
 54 
 
 !!v 
 
INDEX. 
 
 683 
 
 '. I 
 
 " 
 
 Massage .... 
 
 PAGE 
 
 226 
 
 Micturition, disorders of 
 
 PACK 
 
 636 
 
 Menopause, vide "Climac- 
 
 
 »» 
 
 incontinence f 
 
 
 teric" .... 
 
 109 
 
 
 urine 
 
 637 
 
 Menorrhagia. 
 
 119 
 
 II 
 
 i r ri tai)ili t y of 
 
 
 Menstruation 
 
 106 
 
 
 bladder . 
 
 636 
 
 ,, amenorrh(fa 
 
 117 
 
 II 
 
 pains in the urin- 
 
 
 ,, l)iological con- 
 
 
 
 ary tract . 
 
 638 
 
 siderations . 
 
 660 
 
 It 
 
 reten»'()n of urine 
 
 637 
 
 ,, disturlxince of . 
 
 117 
 
 1 1 
 
 suppression of 
 urme 
 
 
 ,, dysmenorrhcL'a . 
 
 121 
 
 
 639 
 
 ,, explanation 
 
 
 Mikulicz's plug 
 
 269 
 
 of 
 
 653 
 
 Minor therapeutic nieasures . 
 
 216 
 
 ,, general phen- 
 
 
 Morcellement 
 
 497 
 
 omena 
 
 106 
 
 Morgagni 
 
 , hyda'id of 
 
 IS 
 
 ,, habit 
 
 I S 
 
 Midler, ducts ci . 
 
 3' 
 
 ,, local pelvic phen- 
 
 
 Myoma 
 
 uteri, see " Fibro- 
 
 
 omena 
 
 106 
 
 myoma 
 
 II 
 
 
 , , menorrhagia 
 
 119 
 
 
 
 
 ,, metrorrhagia . 
 
 H9 
 
 Nabothian follicles 
 
 419 
 
 „ physiological 
 
 
 Needles 
 
 . . . . 
 
 259 
 
 ' ■ absence 
 
 109 
 
 Nerves of pelvis . 
 
 55 
 
 ,, relation to body 
 
 
 Nervous 
 
 system in relation to 
 
 
 l'', meta- 
 
 
 
 hyste r i a 
 
 137 
 
 bolism 
 
 660 
 
 »» 
 
 ,, neuras- 
 
 
 ,, ,, to con- 
 
 
 
 thenia . 
 
 135 
 
 ception 
 
 656 
 
 »» 
 
 „ pelvic 
 
 
 „ ,, to Fal- 
 
 
 
 diseases 
 
 • 132 
 
 lopian 
 
 
 » 
 
 , , reflex 
 
 
 tubes . 
 
 65s 
 
 
 neuroses 140 
 
 ,, ,, to men- 
 
 
 II 
 
 ,, treatment 
 
 tal irre- 
 
 
 
 of pelv 
 
 c 
 
 sponsi- 
 
 
 
 pains . 
 
 140 
 
 : \ . bility . 
 
 131 
 
 Nubility 
 
 . 
 
 104 
 
 ri -^ „; • „ to OATU- 
 
 
 
 
 
 j' lation . 
 
 653 
 
 Operating table . 
 
 258 
 
 „ ,, to rut . 
 
 674 
 
 Operativ 
 
 e measures 
 
 244 
 
 „ . „ to spe- 
 
 
 Organ of Rosenmiiller . 
 
 14 
 
 • 1 
 
 . s c 1 a 1 
 
 
 Ovarian 
 
 artery 
 
 49 
 
 >■:■■■- ■■■ ■ ■■,■■■'''•'-' nerv- 
 
 
 , , cysts, changes in 
 
 384 
 
 ■' ' ■ •'-■•:^'-i:v\:' ■ u s 
 
 
 11 
 
 II gangrene . 
 
 3«7 
 
 : ' ■ ; . mech- 
 
 
 II 
 
 ,, haemorrhage 
 
 387 
 
 V: an ism 
 
 655 
 
 11 
 
 ,, inflammation 
 
 385 
 
 „ type. 
 
 108 
 
 II 
 
 ,, rupture . 
 
 386 
 
 ,, vicarious . 
 
 109 
 
 II 
 
 ,, suppuration 
 
 . 387 
 
 Mesonephros or Wolffian body, 
 
 
 11 
 
 ,, torsion 
 
 • 384 
 
 relics of 
 
 14 
 
 Ovariotomy . 
 
 4CX) 
 
 ,, male homologues 
 
 17 
 
 Ovaritis 
 
 . 
 
 369 
 
 Metritis . . . 426, 427 
 
 Ovary, affections of 
 
 . 367 
 
 Metrorrhagia 
 
 119 
 
 II a 
 
 natomy of 
 
 I 
 
 Micro-organisms in relation to 
 
 
 ,, anomalies . 
 
 • 367 
 
 pelvic diseases . 
 
 146 
 
 ,, attachments 
 
 I 
 
684 
 
 INDEX. 
 
 \ 
 
 M 
 M 
 
 Ovary, broad ligament cysts . 
 ,, changes in ovarian cysts 
 ,, dermoid 
 ,, development 
 ,, double ovarian . 
 ,, hernia 
 
 hydrops folliculorum 
 
 inflammation 
 
 microscopic structure 
 
 minor conditions 
 
 naked - eye appear 
 ance 
 
 ovarian hydrocele 
 
 papillomatous . 
 
 physical signs . 
 
 physiological note 
 
 position and relations 
 
 pregnancy with , 
 
 prolapse . 
 
 proliferating m u 1 1 i 
 locular . 
 
 solid . 
 
 symptoms . 
 
 treatment . 
 
 tuberculosis of . 
 
 tumours of 
 
 varieties . 
 Ovulation in relation to mens 
 
 truation 
 Ovum, development 
 ,, structure . 
 
 II 
 
 M 
 II 
 II 
 II 
 l» 
 
 II 
 II 
 II 
 
 II 
 II 
 II 
 
 Pain in neuroses . 
 
 ,, in pelvic diseases . 
 
 ,, treatment of . 
 Panhysterectomy for fibroids 
 Parametritis chronica atro 
 
 phicans ... 
 Parotitis after abdominal sec 
 
 tion .... 
 Parovarian cysts . 
 Parovarium . 
 Parturition, effect on pelvic 
 
 floor .... 
 Pelveo-peritonitis . 
 Pelvic abscess 
 
 ,, connective tissue . 
 
 , , floor, anatomy of 
 
 ,. ,, broad ligaments, 
 relation of 
 
 PAflK 
 
 384 
 
 6 
 
 395 
 366 
 
 372 
 
 369 
 
 3 
 
 408 
 
 2 
 396 
 376 
 
 391 
 
 8 
 
 2 
 
 398 
 
 368 
 
 373 
 397 
 387 
 399 
 398 
 372 
 372 
 
 653 
 6 
 
 m 
 133 
 141 
 491 
 
 328 
 
 294 
 
 381 
 
 14 
 
 558 
 312 
 326 
 
 73 
 74 
 
 91 
 
 f I 
 II 
 
 II 
 
 Pelvic floor, dissectional view 
 ,, ,, downward dis- 
 
 placements . 
 ,, ,, injuries and dis- 
 placements of 
 ,, ,, injuries to fasciie 
 
 and muscles . 
 ,, ,, meaning of term 
 " pelvic floor " 
 muscles of floor . 
 parietal pelvic 
 
 fascia 
 physics of pelvic 
 
 floor 
 projection 
 rupture of peri- 
 neum 
 sacro-sciatic liga- 
 ments . 
 sectional study . 
 superficial fascia 
 triangular liga- 
 ments . 
 utero-sacral liga- 
 ments . 
 visceral p el v i c 
 fascia . 
 „ anat. ,, 
 ,, anterior 
 layer 
 rectal , , 
 recto- 
 vaginal ,, 
 ,, ,, vesical „ 
 
 ,, ,, vesico- 
 
 vaginal ,, 
 ,, viscera and pas- 
 sages con - 
 n e c t e d 
 with floor 
 ,, ,, bladder 
 
 ,, ,, rectum 
 
 ,, ,, uterus 
 
 ,, ,, vagina . 
 
 ,, wounds of vulva 
 and vagina . 
 ,, peritoneum 
 Perforation of bowel after 
 
 abdominal section 
 Perineal body 
 Perineum, rupture of 
 
 II 
 11 
 
 II 
 II 
 
 II 
 II 
 
 I'Ar.R 
 76 
 
 564 
 
 559 
 562 
 
 74 
 81 
 
 76 
 
 97 
 97 
 
 559 
 
 77 
 94 
 80 
 
 77 
 
 92 
 
 78 
 80 
 
 80 
 79 
 
 79 
 78 
 
 79 
 
 85 
 85 
 87 
 88 
 86 
 
 558 
 71 
 
 293 
 96 
 
 559 
 
INDEX. 
 
 685 
 
 Peritorx 
 
 ium, affections of 
 
 PACK 
 
 298 
 
 Replacing of retroverted 
 
 PACE 
 
 »« 
 
 ,, acute peneral 
 
 
 uterus 
 
 457 
 
 
 peritonitis 
 
 302 
 
 * M „ by the bi- 
 
 
 )( 
 
 „ ,, pelvic „ 
 
 312 
 
 manual 
 
 457 
 
 n 
 
 ,, ch ronic 
 
 
 II ,, in the genu- 
 
 
 
 general „ 
 
 31' 
 
 pectoral 
 
 
 t> 
 
 ,, „ pelvic ,, 
 
 l^l 
 
 |K)sturc 
 
 457 
 
 »» 
 
 , , drainage 
 
 
 II ,, with the sound 
 
 458 
 
 
 of 268, 
 
 278 
 
 Reposition of inverted uterus 
 
 466 
 
 >» 
 
 ,, etiology . 
 
 300 
 
 Retroflexii^i: of uterus . 
 
 449 
 
 >> 
 
 ,, hiematocele 
 
 329 
 
 Retroveisior of uterus, of)era- 
 
 
 »» 
 
 ,, malignant 
 
 
 tions for . 
 
 458 
 
 
 peritonitis 
 
 320 
 
 11 ,, Alquit'-Alex- 
 
 
 »» 
 
 „ new growths 
 
 321 
 
 a n d e r- 
 
 
 >i 
 
 ,, tuberculosis 
 
 317 
 
 Adan"i 
 
 459 
 
 Pessaries .... 
 
 231 
 
 ,, „ Pryor's 
 
 462 
 
 i> 
 
 different forms 
 
 232 
 
 1, „ V a g i n a 1 
 
 
 ») 
 
 method of using 
 
 234 
 
 fixation 
 
 462 
 
 Piles 
 
 • • • • 
 
 643 
 
 ,, ,, ventro- ,, 
 
 460 
 
 Placental polypus . 
 
 538 
 
 ,, ,, ventro- 
 
 
 Polypi 
 
 [)f uterus . 
 
 536 
 
 vesico , , 
 
 461 
 
 Prolapse of ovary . 
 
 368 
 
 „ 11 vesico- ,, 
 
 461 
 
 > t 
 
 rectum 
 
 641 
 
 Richelot- Doyen operation 
 
 359 
 
 i» 
 
 uterus 
 
 564 
 
 Round ligament, anatomy of. 
 
 30 
 
 Pruritus 
 
 ani . 
 
 649 
 
 ,, ,, hydrocele . 
 
 345 
 
 >i 
 
 vulv£E 
 
 550 
 
 11 ,, shortening . 
 
 459 
 
 Pryor's operation . 
 
 462 
 
 ,, ,, tumours of. 
 
 344 
 
 Pseudomyxoma peritonei 
 
 387 
 
 
 
 Puberty 
 
 . 
 
 100 
 
 Salpingitis .... 
 
 347 
 
 Pudendal hernia . 
 
 557 
 
 Salpingo-oophorectomy . 
 
 354 
 
 Pyosalp 
 
 mx . 
 
 350 
 
 Semiprone position 
 
 Sepsis after alxlominal section 
 
 98 
 291 
 
 Rectal examination 
 
 183 
 
 Shock after operation . 
 
 289 
 
 Rectocele .... 
 
 576 
 
 Silk-worm gut 
 
 263 
 
 Recto-vaginal fistula 
 
 643 
 
 Silver-wire sutures 
 
 260 
 
 M 
 
 ,, pouch 
 
 72 
 
 Shortening round ligaments . 
 
 459 
 
 Rectum 
 
 , anatomy of 
 
 68 
 
 Sound, uterine 
 
 198 
 
 >> 
 
 certain affections of . 
 
 641 
 
 ,, method of using . 
 
 199 
 
 >» 
 
 fissure of anus . 
 
 643 
 
 , , points to be observec 
 
 
 >> 
 
 fistula 
 
 644 
 
 before passing . 
 
 199 
 
 3) 
 
 gonorrhoea 
 
 645 
 
 ., use of . 
 
 201 
 
 >} 
 
 haemorrhoids 
 
 643 
 
 Speculum, rectal . 
 
 183 
 
 »> 
 
 new growths 
 
 645 
 
 ,, spatular 
 
 189 
 
 ' >> 
 
 prolapse . 
 
 641 
 
 ,, tubular . 
 
 192 
 
 >» 
 
 pruritus . 
 
 649 
 
 ,, vaginal. 
 
 1S8 
 
 >» 
 
 rectocele , . 576, 641 
 
 ,, valvular 
 
 193 
 
 >> 
 
 recto-vaginal fistula . 
 
 643 
 
 ,, vesical . 
 
 185 
 
 »> 
 
 relation to pelvic 
 
 
 Sponges and swabs 
 
 247 
 
 
 floor 
 
 8/ 
 
 Sponge-tents 
 
 207 
 
 ) J 
 
 stricture . 
 
 649 
 
 Staffordshire knot . 
 
 266 
 
 »> 
 
 ulceration 
 
 645 
 
 Subinvolution 
 
 427 
 
 ill 
 
s.. 
 
 T 
 
 686 
 
 INDEX, 
 
 Supcrinvolution of uterus 
 
 I'Ar.K 
 440 
 
 Uterus, 
 
 anatomy of 
 
 l'A(iK 
 
 18 
 
 Sutures, diU'crcnt forms of 
 
 260 
 
 >i 
 
 at different periods of 
 life . . 
 
 26 
 
 
 
 II 
 
 atresia of cervix 
 
 416 
 
 Tangle-tents. 
 
 209 
 
 1) 
 
 atrophy of 
 
 4" 
 
 Tents 
 
 207 
 
 »> 
 
 biangularis 
 
 417 
 
 Torsion of pedicle of ovarian 
 
 
 >> 
 
 bicornis . 
 
 410 
 
 tumours . . . . 
 
 3«4 
 
 1) 
 
 biforis 
 
 417 
 
 Triangular ligaments 
 
 76 
 
 »» 
 
 bipartitus . 
 
 4IU 
 
 Tuberculosis. 
 
 157 
 
 1 1 
 
 blood cyst of wall 
 
 502 
 
 'i'ubo-ovarian abscess . 
 
 351 
 
 »> 
 
 carcinoma 
 
 536 
 
 Tupelo-tents 
 
 209 
 
 >> 
 
 cervical carcinoma . 
 
 505 
 
 
 
 )« 
 
 complete absence 
 
 409 
 
 
 
 ) ) 
 
 comjKinent parts 
 
 18 
 
 Ureters, anatomy of 
 
 62 
 
 ) ) 
 
 corporeal carcinomii . 
 
 522 
 
 ,, anomalies of . 
 
 620 
 
 > > 
 
 cystic adenomyoma . 
 
 SOI 
 
 ,, examination of 
 
 •«5 
 
 ) t 
 
 ,, distensions of . 
 
 36s 
 
 Uretero-cervical fistula . 
 
 635 
 
 »i 
 
 ,, fibromyoma 
 
 500 
 
 ,, vaginal ,, . 
 
 634 
 
 M 
 
 ,, tumours of 
 
 500 
 
 Urethra, absence of 
 
 602 
 
 ) > 
 
 development . 
 
 31 
 
 „ affections of . 
 
 602 
 
 >» 
 
 didelphys . 
 
 410 
 
 „ anatomy of . 
 
 60 
 
 I) 
 
 differential diagnosis . 
 
 513 
 
 . j, angioma 
 
 605 
 
 11 
 
 displacements . 
 
 445 
 
 ,, bacteriology of 
 
 148 
 
 >> 
 
 ,, anteflexion 
 
 447 
 
 , , caruncle 
 
 60s 
 
 I) 
 
 ,, anteversion 
 
 445 
 
 „ dilatation 
 
 603 
 
 M 
 
 ,, inversion . 
 
 463 
 
 ,. „ displacement . 
 
 603 
 
 >} 
 
 ,, lateriflexion 
 
 445 
 
 , „ epispadias 
 
 602 
 
 >> 
 
 ,, lateriversior 
 
 »445 
 
 > „ fissure . 
 
 605 
 
 }> 
 
 ,, retroflexion 
 
 449 
 
 ,. „ ^ hypospadias . 
 
 603 
 
 11 
 
 ,, retroposition 463 
 
 „ prolapse 
 
 605 
 
 »• 
 
 , , retroversion 
 
 449 
 
 ,, urethritis 
 
 603 
 
 >1 
 
 embryolog ' 
 
 29 
 
 ,, urethrocele 
 
 604 
 
 >> 
 
 etiology . 
 
 505 
 
 Urethro- vaginal fistula . 
 
 634 
 
 » > 
 
 extension . 
 
 510 
 
 Urinary tract, development o 
 
 f 64 
 
 11 
 
 fibrinous . 
 
 538 
 
 Urine, incontinence of . 
 
 . 637 
 
 } 1 
 
 fibromyoma lym- 
 
 
 ,, suppression of . 
 
 ■ 639 
 
 
 phangiectodes 
 
 500 
 
 Urogenital sinus . 
 
 . 6s 
 
 )> 
 
 ,, teleangiectodes 
 
 500 
 
 Uterine douche 
 
 . 221 
 
 )) 
 
 fibrous 
 
 538 
 
 ,, medication 
 
 • 223 
 
 l> 
 
 general symptoms 
 
 512 
 
 „ plug. 
 
 . 222 
 
 M 
 
 high amputation 
 
 514 
 
 Utero-sacral ligaments, anatoi 
 
 «y 31 
 
 ;> 
 
 hypertrophy 
 
 436 
 
 U M ,»l J"fla" 
 
 1- 
 
 >> 
 
 imperfect develop- 
 
 
 mati 
 
 on 321 
 
 
 ment of 
 
 411 
 
 Uterus, alxiominal extirpatioi 
 
 1 519 
 
 It 
 
 incudiformis 
 
 417 
 
 ,, abnormal communica 
 
 
 ) ? 
 
 infantile . 
 
 411 
 
 tions 
 
 . 416 
 
 1) 
 
 inflammation . 
 
 417 
 
 „ abnormal folding o 
 
 f 
 
 11 
 
 laceration 
 
 441 
 
 cervix . 
 
 . 417 
 
 )> 
 
 ligaments 
 
 30 
 
 V ..,,,' acollis 
 
 . 417 
 
 11 
 
 local 
 
 5" 
 
 ,, affections of 
 
 • 409 
 
 II 
 
 malformations . 
 
 409 
 
 I 
 
INDEX. 
 
 «y 
 
 I'AGK 
 l8 
 
 26 
 
 416 
 
 411 
 
 417 
 
 410 
 
 417 
 
 4IU 
 502 
 
 536 
 
 505 
 409 
 
 18 
 
 522 
 
 501 
 
 365 
 
 500 
 
 500 
 
 31 
 
 410 
 
 513 
 
 445 
 
 447 
 
 » 445 
 
 463 
 
 1 445 
 
 "445 
 
 449 
 
 463 
 
 449 
 29 
 
 505 
 510 
 
 538 
 
 500 
 500 
 
 538 
 512 
 514 
 436 
 
 411 
 
 417 
 411 
 
 417 
 441 
 
 30 
 
 5" 
 409 
 
 
 
 I' ACE 
 
 
 
 
 PArii 
 
 Uterus, 
 
 measurements . 
 
 (8 
 
 Uterus, 
 
 vaginal extirpation. 
 
 
 M 
 
 minor malformations 
 
 417 
 
 
 ligature 
 
 • • 
 
 516 
 
 It 
 
 movements, norlnal . 
 
 29 
 
 
 
 
 «r 
 
 tl 
 
 mucosa of cervix 
 
 25 
 
 Vagina 
 
 abnormal ope 
 
 nings . 
 
 600 
 
 If 
 
 „ ,, corpus . 
 
 20 
 
 »» 
 
 affections of 
 
 1 • 
 
 S8i 
 
 l» 
 
 mucous . 
 
 536 
 
 M 
 
 anatomy of 
 
 , , 
 
 33 
 
 M 
 
 musculature 
 
 20 
 
 », 
 
 atresia, ac(juired 
 
 59 » 
 
 It 
 
 new yrowllis , 
 
 470 
 
 t» 
 
 ,, conge 
 
 nital 
 
 592 
 
 II 
 
 ,, carcinoma 
 
 505 
 
 ) 1 
 
 bulbs of the 
 
 , 
 
 46 
 
 II 
 
 ,, cystic 
 
 
 >> 
 
 carcinoma 
 
 , , 
 
 589 
 
 
 tumours 
 
 500 
 
 , f 
 
 changes after 
 
 puberty 
 
 73 
 
 11 
 
 ,, deciduoma 
 
 
 11 
 
 ,, ,, menopause 37 
 
 
 malignum 530 
 
 »> 
 
 cysts 
 
 . 587 
 
 , 600 
 
 »l 
 
 ,, fibromyoma 470 
 
 , 1 
 
 development 
 
 . , 
 
 36 
 
 II 
 
 ,, sarcoma . 
 
 526 
 
 ,, 
 
 fibroma and fil 
 
 jroinyoma 588 
 
 II 
 
 notes on Milllerian 
 
 
 ,» 
 
 inflammation 
 
 , , 
 
 sSi 
 
 
 tracts in vertebrata 
 
 '32 
 
 > I 
 
 in genu-jx-'cto 
 
 ral posture "98 
 
 II 
 
 operations in carci- 
 
 
 >» 
 
 physiological 
 
 note 
 
 35 
 
 
 noma of 
 
 SH 
 
 ,, 
 
 position . 
 
 • • 
 
 34 
 
 II 
 
 papilloma 
 
 539 
 
 >» 
 
 sarcoma . 
 
 * • 
 
 590 
 
 »i 
 
 parvicollis 
 
 417 
 
 M 
 
 septate 
 
 , 
 
 599 
 
 M 
 
 pathology 
 
 506 
 
 », 
 
 stenosis . 
 
 . 
 
 590 
 
 >l 
 
 pedunculated cystic 
 
 
 » 
 
 structure . 
 
 , , 
 
 34 
 
 
 growth 
 
 420 
 
 », 
 
 tuberculosis 
 
 • • 
 
 590 
 
 >> 
 
 pedunculated Naboth- 
 
 
 >> 
 
 tumours . 
 
 a , 
 
 587 
 
 
 ian follicle . 
 
 419 
 
 >» 
 
 unilateral . 
 
 , , 
 
 599 
 
 >) 
 
 peritoneum of . 
 
 20 
 
 Vaginal fixation of uterus 
 
 462 
 
 )) 
 
 physical signs . 
 
 512 
 
 II 
 
 medication 
 
 
 220 
 
 1 ) 
 
 placental . 
 
 538 
 
 t» 
 
 plug 
 
 
 219 
 
 )) 
 
 polypus . 
 
 536 
 
 >» 
 
 section 
 
 
 295 
 
 >> 
 
 position . 
 
 26 
 
 Vaginismus . 
 
 
 586 
 
 U 
 
 premature develop- 
 
 
 Vaginitis 
 
 
 581 
 
 
 ment . 
 
 417 
 
 Veins of pelvis 
 
 
 54 
 
 >> 
 
 prognosis . 
 
 514 
 
 Ventral fixation of uterus 
 
 460 
 
 >> 
 
 prolapsus of 
 
 564 
 
 Ventre 
 
 »-vesico-fixation of uterus 461 
 
 J1 
 
 rudimentary uterus . 
 
 409 
 
 Vesico-fixation 
 
 M >, 
 
 461 
 
 >l 
 
 sarcoma . 
 
 536 
 
 Vestibule 
 
 , 
 
 45 
 
 >, 
 
 septus 
 
 411 
 
 Volsella 
 
 • • 
 
 195 
 
 >> 
 
 stenosis . 
 
 433 
 
 Vulva, 
 
 affections of 
 
 , 
 
 541 
 
 l> 
 
 structure . 
 
 20 
 
 }» 
 
 atresia 
 
 . 
 
 541 
 
 ,1 
 
 submucous fibroid 
 
 536 
 
 ,> 
 
 carcinoma . 
 
 . 536, 553 
 
 >, 
 
 treatment when disease 
 
 ,, 
 
 changes in clitoris anc 
 
 
 
 can be removed 514 
 
 
 labia 
 
 
 541 
 
 »> 
 
 ,, ,, cannot ,, 
 
 520 
 
 I, 
 
 defectus 
 
 
 541 
 
 >) 
 
 tuberculosis 
 
 529 
 
 ,> 
 
 double 
 
 
 541 
 
 }> 
 
 unicornis . 
 
 410 
 
 )) 
 
 eczema 
 
 
 546 
 
 >J 
 
 vaginal extirpation . 
 
 514 
 
 )» 
 
 elephantiasis 
 
 
 552 
 
 >1 
 
 „ „ after- 
 
 
 )> 
 
 enchondroma 
 
 
 555 
 
 
 results 
 
 524 
 
 ,) 
 
 erysipelas . 
 
 
 549 
 
 >l 
 
 „ „ clamp 
 
 
 >> 
 
 fibroma 
 
 
 554 
 
 
 method 
 
 518 
 
 >> 
 
 fibromyoma 
 
 
 ■ 555 
 
688 
 
 INDEX. 
 
 PAGE 
 
 PAGE 
 
 Vulva, gangrene . 
 
 546 
 
 Vulva, pseudo-hermaphroditism 543 
 
 
 , hoematoma 
 
 550 
 
 ,, sarcoma . . -553 
 
 
 , hermaphroditism 
 
 543 
 
 ,, tuberculosis . . 549 
 
 
 , hernia 
 
 557 
 
 „ varix, . . -549 
 
 
 , herpes 
 
 548 
 
 ,, venereal affections . 556 
 
 
 , hypospadias 
 
 543 
 
 ,, wounds . . . 557 
 
 
 , infantile 
 
 541 
 
 Vulvitis .... 545 
 
 
 , inflammation 
 
 545 
 
 
 
 , kraurosis . 
 
 550 
 
 Weir Mitchell treatment . 145 
 
 
 , lif>oma 
 
 554 
 
 Wolffian body . . • 14 
 
 
 , lupus. 
 
 548 
 
 ,, duct ... 64 
 
 
 , malformations of 
 
 541 
 
 ,, relics ... 14 
 
 
 , myxoma 
 
 • 554 
 
 Wolfler's method of hysterec- 
 
 
 , oedema 
 
 546 
 
 tomy . . . . 491 
 
 
 , papillary growths 
 
 • 554 
 
 Wounds, drainage of . . 268 
 
 
 , persistence of cloaca 
 
 . 543 
 
 
 
 , pruritus 
 
 ■ 550 
 
 Zona pellucida ... 5 
 
 ' W 
 
 
 
 \ 
 
 I 
 
 \\ 
 
 > 
 
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