B 477037

141
ARTES
1837
SCIENTIA
VERITAS
LIBRARY
OF THE
UNIVERSITY OF MICHIGAN
FLURIBUS UND
SI-QUAERIS PENINSULAM AMOENAMU,
CIRCUMSPICE
"

V.U.O.
V.R..0
V.LR
V.U.
V.I.E.
V.E.
V.I
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PLATE I.
V.C.
A A
A.R
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AIG
P.P.
P.V..
A.U.O.
A.P
L.R
A.U.
A.V
~A.V.H.
ALE
AE
A.I.
ALE
SCHEMA OF THE GENITAL CIRCULATION (Auvard and Devy).
A. A. Aorta. V. C. Inferior Vena Cava. A. R. Renal Artery. V. R. Renal Vein.
A. U. o. Ovarian Artery. V. U. O. Ovarian Vein. A. 1. G. Left Common Iliac
Artery. V.I. D. Right Common Iliac Vein. A. I. E. External Iliac Artery.
A. I. Internal Iliac Artery. V. I. E. External Iliac Vein. V. I. Internal Iliac
Vein. A. E. Epigastric Artery, giving off A. L. R., Artery of the Round Ligament
(L. R.). V. E. Epigastric Vein, receiving v. L. R., Vein of the Round Ligament.
A. P. Puerperal Artery. P. P. Pampiniform Plexus. A. U. Uterine Artery. v. U.
Uterine Veins. A. V. Vaginal Arteries. P. V. Vaginal Plexus. A. V. H. Vulvo-
Vaginal Branch of the Internal Pudic Artery. V. B. Veins emptying into the
Internal Pudic Vein and also into the External Hemorrhoidal Veins. B. Bulb
of the Vagina. V. Vulva. U. Uterus. T. Fallopian Tube. o. Ovary.
v.
A TEXT-BOOK
OF
GYNECOLOGY.
5286 ==
BY
JAMES C. WOOD, A.M., M.D.,
PROFESSOR OF GYNECOLOGY IN THE CLEVELAND MEDICAL College; for eight YEARS PROFESSOR
OF OBSTETRICS AND THE DISEASES OF WOMEN AND CHILDREN IN THE University of
MICHIGAN, HOMEOPATHIC DEPARTMENT; FELLOW OF THE BRITISH GYNECOLOGICAL
SOCIETY; FOUNDER MEMBER OF THE INTERNATIONAL PERIODIcal congress of
GYNECOLOGY AND OBSTETRICS, AND AN HONORARY PRESIDENT OF THE BELGIUM
SESSION OF 1892; EX-PRESIDENT OF THE HOMEOPATHIC MEDICAL SOCIETY
OF THE STATE OF MICHIGAN; MEMBER OF THE AMERICAN INSTITUTE
OF HOMEOPATHY; HONORARY MEMBER OF THE HOMEOPATHIC
MEDICAL SOCIETY OF THE STATE OF NEW YORK, ETC.
WITH TWO HUNdred and ten ILLUSTRATIONS.
PHILADELPHIA:
BOERICKE & TAFEL.
1894.
COPYRIGHTED, 1893, BY BOERICKE & TAFEL.
PRESS OF WM. F. FELL & CO.,
1220-24 SANSOM ST.,
PHILADELPHIA.
ΤΟ
THE MEMORY OF
My Father, Major Henry E. Wood,
AND
My Mother,
THIS BOOK IS AFFECTIONATELY DEDICATED BY
THE AUTHOR.
•
PREFACE.
When, four years ago, the publishers of this volume, Messrs.
Boericke and Tafel, requested me to write a text-book on gyne-
cology, I consented to undertake the task only after receiving
assurances from them that their views were in entire harmony
with my own, regarding the field to be covered by such a work.
An ideal text-book, according to my conception, was one which
should not only embody in concise form for the specialist the
most advanced teachings of the American and European schools
of gynecology, but should present these teachings in such a way
as to enable the student of medicine and the non-specialist to
obtain at least an intelligent knowledge of the subject without
exhaustive research. That I have fallen far short of this high
ideal in the succeeding pages is apparent to no one more plainly
than to myself: yet I have had it constantly in mind. An experi-
ence of nine years as a teacher of gynecology has convinced me
that minutiæ are essential to the successful teaching of this most
important branch of medicine. I have, therefore, endeavored
to lead the student on, step by step, into the broad field of the
specialty, first dealing with those preliminaries without which
he is ill-fitted to proceed further. I have devoted much space
to diagnosis, especially to the diagnosis of abdominal tumors,
believing most emphatically that blind gynecology has been the
curse of womankind. I have introduced more than the usual
number of illustrations and clinical cases, a feature which, I think,
will aid the reader greatly in comprehending the text. Finally,
I have endeavored so to present the treatment of the various
affections dealt with that the busy practitioner may, without un-
necessary loss of time, bring to his gynecological patients those
agents and methods which have been devised and are now being
employed by the leading specialists of both schools.
V
vi
PREFACE.
With the foregoing objects in mind I have largely eliminated
historical data and profitless discussion of theories, at all times
referring the reader for more extended information to special
literature. I have also omitted the usual chapters devoted to
diseases of the breast and diseases of the rectum, subjects which,
although essentially gynecological, have come to be treated in
various special works devoted to them.
I cannot but feel that the profession will, appreciate the large
number of illustrations from the Museum of the Royal College
of Surgeons, London. I am not aware that any American
specialist has before utilized that splendid pathological collection
for this purpose. All of the photographs of these specimens, as
well as photographs and drawings obtained from my own cases,
were taken under my personal supervision.
In the several series of illustrative cases, it has been my aim to
introduce only those which serve to illustrate or emphasize the
points dealt with in the text. Whenever such points are better
illustrated by unsuccessful cases I have not hesitated to record
my failures.
In conclusion, I desire to acknowledge my indebtedness to
the publishers of "The Annual of Universal Medical Sciences,"
in providing me with references and advanced proof-sheets
of that most excellent publication; to Mr. Frederic S. Eve,
curator of the Museum of the Royal College of Surgeons, for
his kindness in granting me unusual privileges in photographing
specimens; to Messrs. Geo. Tiemann & Co., for having pre-
pared for me new electrotypes of the instruments illustrated;
and to my assistants, Drs. Mary Denison, Ida C. Woolsey,
Evelyn S. Pettit, and C. M. Thurston, for having rendered me
invaluable service in the way of research, proof-reading, trans-
lating, etc.
CLEVELAND, January 15, 1894.
JAMES C. WOOD.
CONTENTS.
CHAPTER I.
THE CAUSES OF GYNECOLOGICAL DISEASES.
Inherited Feebleness of Constitution.-Defects in or Absence of Develop-
ment.-Acquired Feebleness of Constitution.-Deficient Air and Ex-
ercise.-Improper Dress.-Exposure During Menstruation.-Improper
Care During and After Parturition.-Reflex Functional Disturbance
and Nervous Disorders.-Development of New Growths and Malignant
Disease. Inflammatory.-Accidental
CHAPTER II.
THE ANATOMY OF THE FEMALE PELVIC ORGANS.
Embryology.-Development of Ovum, Showing Successive Changes Fol-
lowing Fecundation.-External Genitals. Muscles of the Female
Perineum. The Vulvo-Vaginal Glands.-The Fascia of the Pelvic
Floor.-Deeper Fascia.-The Perineal Septum or Triangular Liga-
ment.-The Pelvic Floor Dissected from Above-Fascial Coverings
of the Muscles of the Pelvic Floor.-The Relations of the Pelvic
Organs with the Pelvis and with One Another.-Peritoneum.—Round
Ligaments.-Pelvic Pouches.-Cellular or Connective Tissue of Pelvis.
The Uterus and Annexa.-The Vagina.-Blood-Vessels, Lymphatics,
and Nerves.
PAGES
17-29
30-57
CHAPTER III.
CASE TAKING.
Case Record. The Significance of Pain in Diagnosis:-As Regards Loca-
tion-As Regards Function-As Regards Posture.
CHAPTER IV.
THE SIGNIFICANCE OF DISCHARGES IN DIAGNOSIS.
Physiology. Pathology :
G
Mucous Purulent-Watery - Sanious-Of-
fensive-Hemorrhagic.-Diagnosis of Bodies Expelled from the Va-
gina.-The Microscope as a Means of Diagnosis.
CHAPTER V.
PHYSICAL EXAMINATION.
Instruments and Appliances Necessary for Diagnosis.-Positions for Exami-
nation
•
CHAPTER VI.
PHYSICAL EXAMINATION.-(Continued.)
Immediate Touch.-Vaginal Touch.-Rectal Touch.-Vesical Touch.-
Double Touch.-Conjoined Manipulation
58-69-
70-76.
77-92
93-104
vii
viii
CONTENTS.
CHAPTER VII.
PHYSICAL EXAMINATION.-(Continued.)
Intermediate Touch:-Uterine Sound-Vesical Sound.-Immediate Sight:
-External Inspection-Per Speculum.-Produced Sounds :-Percus-
sion.-Existing Sounds :-Auscultation.-Conclusions
CHAPTER VIII.
THE GENERAL PATHOLOGY OF GYNECOLOGICAL DISEASES.
Preliminary Considerations.-Nervous and Blood Supply of the Pelvic
Organs. How Distant Organs are Involved.-Nature of the Local
Lesion Causing Reflex Symptoms.-Forms of Hyperemia.-The Se-
quelæ of Hyperemia.-The Neuroses.-How General Symptoms are
Induced by Local Disease.-How Local Disease is Induced by General
Symptoms.-Temperament and Constitutional Bias.
CHAPTER IX.
GENERAL TREATMENT OF GYNECOLOGICAL DISEASES.
PAGES
105-116
117-123
General Considerations.-Indigestion.-Constipation.-Nervous Prostration. 124-137
CHAPTER X.
LOCAL TREATMENT OF GYNECOLOGICAL DISEASES.
General Considerations.-The Vaginal Douche.-Local Applications.—
Astringents and Styptics.-Narcotics.-Disinfectants.-Caustics.-The
Vaginal Tampon.
CHAPTER XI.
ELECTRICITY IN GYNECOLOGY.
General Considerations.-Galvanism.-Faradism.-The Franklinic Current.
-Apparatus: -- Galvanometer-Water Rheostat - Electrodes - The
Application of the Franklinic Current.-In Amenorrhea.-In Dysmen-
orrhea.-In Subinvolution.-In Superinvolution and Atrophy.—In
Ovaralgia.-In Chronic Ovaritis.-In Chronic Pelvic Inflammation.-
In Uterine Displacements.-In Endometritis.-Schema
CHAPTER XII.
ANTISEPSIS IN GYNECOLOGY.
138-151
152-169
General Considerations.-The Agents Employed.-The Operator and As-
sistants. The Patient.-The Operating Room.-The Operation.-The
After-treatment.-Antisepsis in Ordinary Gynecological Examinations. 170-183
CHAPTER XIII.
THE HYSTERO-NEUROSES; HYSTERIA.
Definition.-General Considerations.-Forms of Hystero-Neuroses.—The
Physiological Hystero-Neuroses.-Diagnosis.-Prognosis.
CHAPTER XIV.
THE HYSTERO-NEUROSES; HYSTERIA.-(Continued.)
Symptomatology.-Disorders of Sensibility.-Alterations of Motility.—
Circulatory Disturbances.-Anomalies of Secretion and Excretion.—
Disorders of Respiration.
•
184-191
·
192-208
CONTENTS.
ix
CHAPTER XV.
THE HYSTERO-NEUROSES; HYSTERIA.-(Continued.)
Disorders of the Gastro-Intestinal Canal.-Disorders of the Skin.-Gland-
ular Disturbances.-Disorders of the Nervous System.-Epilepsy as a
Hystero-Neurosis.-The Hysterical Paroxysm.
CHAPTER XVI.
MENSTRUATION AND ITS DISORDERS.
PAGES
209-225
Physiology of Menstruation.-General Considerations.-Definition.—Theo-
ries.-Source of Hemorrhages.-Changes in Endometrium.-Amenor-
rhea :-Primary-Secondary-Retention of the Flow-Treatment.. 226-237
CHAPTER XVII.
UTERINE HEMORRHAGE.
General Considerations.- Causes.-Conclusions.-Treatment :— General-
Conduct of Patient During the Period-Treatment of Local Causes-
Immediate Control of Hemorrhage―Therapeutics
CHAPTER XVIII.
DYSMENORRHEA.
•
238-256
Schema Of.-General Considerations.-Neuralgic.-Ovarian.-Congestive
and Inflammatory.—Obstructive.-Membranous.-Treatment .
CHAPTER XIX.
MENOPAUSE.
•
. 257-279
Definition.—Anatomical Changes.- Symptoms.-Treatment.— Illustrative
Cases.
280-289
CHAPTER XX.
VICARIOUS MENSTRUATION.
Definition and Synonyms.-Schema Of.-Theories.-Treatment.
CHAPTER XXI.
STERILITY AND IMPOTENCE.
290-305
Causes.-Treatment.-Dyspareunia. .
CHAPTER XXII.
DISEASES OF THE EXTEernal OrgaNS OF GENERATION.
General Considerations.-Deformities of the Vulva.-Eruptions.—Vulvitis.
-Phlegmonous Inflammation of the Labia Majora.—Inflammation and
Abscess of the Vulvo-Vaginal Glands.-Pudendal Hemorrhage.-
Pudendal Hematocele.-Pudendal Hernia.-Hydrocele.-Edema of
the Labia Majora and Nymphæ.-Neoplasms of the Vulva.
CHAPTER XXIII.
306-319
•
320-341
DISEASES OF THE EXTERNAL Organs of GeneraTION.—(Continued.)
Pruritus Vulvæ; Hyperesthesia of the Vulva.
342-351
X
CONTENTS.
PAGES
• 352-362
CHAPTER XXIV.
VAGINISMUS; COCCYGODYNIA
CHAPTER XXV.
CONGENITAL AND ACQUIRED MalformATIONS AND DISEASES
OF THE VAGINA.
Atresia Vulvæ.- Imperforate Hymen.- Persistent Hymen.-Congenital
Atresia Vaginæ.-Acquired Atresia Vaginæ.-Double Vagina.—Double
Hymen.-Vaginal Cysts.-Hermaphrodism
CHAPTER XXVI.
Anatomy.-Varieties.-Treatment
VAGINITIS.
363-377
• 378-387
CHAPTER XXVII.
SENILE OR ADHESIVE Vaginitis.
General Considerations and History.-Diagnosis and Prognosis.-Etiology
and Pathology.-Treatment.
CHAPTER XXVIII.
ACUTE INFLAMMATORY DISEASES OF THE PELVIC ORGANS AND
Tissues.
Acute Metritis and Endometritis. -Acute Pelvic Cellulitis and Peritonitis.
Acute Ovaritis and Salpingitis.
•
CHAPTER XXIX.
CHRONIC METRITIS AND ENDOMETRITIS.
Chronic Cervical Endometritis and Granular and Cystic Degeneration of
the Cervix.- Chronic Corporeal Endometritis and Uterine Fungosities.
-Chronic Metritis (Subinvolution, Hypertrophy, and Areolar Hyper-
plasia of the Uterus).
CHAPTER XXX.
PELVIC HEMATOCELE.
Intra-Peritoneal.-Extra-Peritoneal
388-397
398-428
429-462
463-479
CHAPTER XXXI.
PELVIC ABSCESS.
General Considerations.-Symptoms.-Differentiation.-Prognosis.—Treat-
ment
•
480-49
CHAPTER XXXII.
DISEASES of the Urethra and Bladder.
Acute Urethritis.-Acute Cystitis.-Chronic Urethritis and Cystitis.
492-505
CONTENTS.
xi
CHAPTER XXXIII.
DISEASES OF THE URETHRA AND BLADDER.-(Continued.)
Malformations of the Urethra.-Stricture of the Urethra.-Prolapse of the
Mucous and Submucous Tissues of the Urethra.-Dilatation of the
Urethra. Fissure of the Urethra.-Vascular Neoplasms of the Urethra.
-Urethral Caruncles.-Polypi of the Urethra.-Irritable Urethra.-Ves-
icai Calculi.-Neoplasms of the Bladder.-Vesical Parasites.-Hema-
tura.-Irritability of the Bladder.-Retention of Urine.
CHAPTER XXXIV.
FISTULÆ OF THE FEMALE GENITAL Organs.
Vesico-Vaginal. Urethro-Vaginal. Uretero-Vaginal.- Vesico-Uterine.—
Uretero-Uterine
PAGES
506-517
518-536
CHAPTER XXXV.
FECAL FISTULÆ.
Recto-Vaginal.—Recta-Labial.—Entero-Vaginal.--Entero-Vesical. . . . 537–542
CHAPTER XXXVI.
DISPLACEMENTS OF THE Uterus.
General Considerations.-Etiology.-Symptoms.-Anteversion.-Anteflex-
ion.-Retroversion.-Retroflexion
CHAPTER XXXVII.
543-567
DISPLACEMENTS OF THE UTERUS.~(Continued.)
Lateral Displacements.-Prolapse of the Uterus.-Inversion of the Uterus. 568-582
CHAPTER XXXVIII.
FIBROID TUMORS OF THE UTERUS.
Definition.-Varieties.-Pathology.-Degenerative Changes.-Etiology.-
Symptoms. Physical Signs.-Progress and Termination.-Prognosis. 583-598
CHAPTER XXXIX.
FIBROID TUMORS OF THE UTERUS.-(Continued.)
Palliative Treatment.-Surgical Treatment.-Oöphorectomy For.-Abdom-
inal Section For.-Fibroids During Pregnancy.-Fibro-Cystic Tumors
of the Uterus
CHAPTER XL.
599-614
615-626
POLYPI OF THE UTERUS: THERAPEUTICS OF UTERINE FIBROMATA
AND POLYPI
CHAPTER XLI.
MALIGNANT DISEASES OF THE UTERUS.
Carcinoma of the Cervix.-Carcinoma of the Body of the Uterus.-Sar-
coma Uteri.
627-640
xii
CONTENTS.
CHAPTER XLII.
MALIGNANT DISEASES OF THE UTERUS.-(Continued.)
PAGES
Treatment of Carcinoma and Sarcoma of the Uterus:-Palliative-Surgical. 641-662
CHAPTER XLIII.
CYSTIC AND ALLIED Diseases of THE UTERINE APPENDAGES.
Ovarian Tumors.-Simple Cysts.-Multiple Cysts.-Proliferous Cysts.-
Dermoid or Cutaneous Proliferous Cysts.-Papillomatous Cysts.-Cysts
of the Broad Ligament.-Papillomatous Cysts.-Parovarian Cysts.-
Enlargement of the Hydatid of Morgagni.-Solid Tumors of the
Ovary :-Fibroma-Carcinoma-Sarcoma.-The Pedicle of Ovarian
Tumors.
663-672
CHAPTER XLIV.
CYSTIC AND ALLIED DISEASES OF THE UTERINE APPENDAges.
-(Continued.)
Symptoms.-Course and Termination of Ovarian Tumors
CHAPTER XLV.
673-682
CYSTIC AND Allied DISEASES OF THE UTERINE APPENDAGES.
—(Continued.)
Diagnosis of Ovarian Tumors.-Differentiation.—Method of Tapping
Ovarian Cysts .
683-701
CHAPTER XLVI.
OVARIOTOMY.
The General Principles of Abdominal Section.—When Ovariotomy Should
be Performed. Operating Table.-Clothing-Preliminary Details.-
Temperature of the Room.-Arrangement of Instruments.-Abdominal
Incision. Intra-Abdominal Manipulations.-Tapping the Cyst.-Man-
agement of Adhesions.-Treatment of Pedicle.-Drainage.-Closing
the Abdominal Wound.-Dressing the Wound.-Incomplete Ovariot-
omy.-Encapsulated Ovarian Cysts.
CHAPTER XLVII.
Ovariotomy.—(Continued.)
After-treatment.—The Pulse and Temperature.-Tympanites.-Septicemia
and Peritonitis.-Therapeutics.-Illustrative Cases.
CHAPTER XLVIII.
INFLAMMATORY DISEASES OF THE UTERINE APPENDAGES.
702-723
•
724-736
Acute Salpingitis and Ovaritis.—Non-Cystic Oöphoro-salpingitis.— Cystic
Oöphoro-salpingitis.- Pathology.-Progress and Termination.- Prog-
nosis.
CHAPTER XLIX.
INFLAMMATORY DISEASES OF THE UTERINE APPENDAGES.—
(Continued.)
Treatment of Non-Cystic and Cystic Oöphoro-salpingitis: -Palliative-Sur-
gical. Illustrative Cases.
•
737-753
754-762
CONTENTS.
xiii
Diseases of the UTERINE APPENDAGES.—(Continued.)
Congestion of the Ovary.-Prolapse of the Ovary.—Ovarian Neuralgia
(Ovaralgia)
CHAPTER L.
ECTOPIC PREGNANCY.
PAGES
•
763-768
—
Definition.- Varieties. Etiology.- Pathology.—Symptoms. Differential
Diagnosis. Prognosis.—Treatment.-Use of Electricity In.-Laparot-
omy For.-Elytrotomy or Vaginal Extraction.-Illustrative Cases. 769-800
CHAPTER LI.
LACERATIONS OF THE CERVIX UTERI.
•
History and General Considerations.—Frequency.—Etiology.-Varieties.—
Pathology.-Symptoms.- Differential Diagnosis.- Prognosis.—Treat-
ment.-Indications for Trachelorrhaphy.-Operation .
CHAPTER LII.
LACERATIONS AND INJURIES OF THE PERINEUM AND PELVIC
FLOOR.
General Considerations and Anatomy.-Forms of Injury.-Causes.-Spon-
taneous Reparation.— Results. Treatment: Palliative-Primary
Operation - Secondary Operation — Flap-Splitting Operation — Em-
met's Operation-Hegar's Operation-The Author's Operation—
Stoltz's Operation for Cystocele.-After-treatment of Colpoperineor-
rhaphy.
801-814
815-846
ILLUSTRATIVE CASES.
PAGE
Profound Neurasthenia with Hystero-Epileptic Convulsions. The Weir Mitchell
Treatment,
130
Neurosis of the Anterior Tibial Region Simulating Periostitis, Cured by
Emmet's Operation, .
196
by Directing Treatment to Pelvis,
196
•
197
200
Hysterical Joint of Three Years' Duration, Simulating Morbus Coxarius, Cured
Distressing Hyperesthesia of Sight and Hearing, .
Reflex Paraplegia, Due to Anteversion and Urethral Fissure,.
Cardiac Neurosis, Resulting in Organic Disease, Associated with, and Probably
caused by, Laceration of the Cervix. Greatly Relieved by Emmet's Opera-
tion,
Cardiac Neurosis, Simulating Exophthalmic Goiter, Caused by Retroversion
and Endometritis, .
•
203
203
Cardiac Pain, Simulating Angina Pectoris, due to Pelvic Lesions,
Circumscribed Erythema of the Lower Limbs, Cured by Correcting a Retrodis-
placement,.
204
•
•
204
Menorrhagia with Marked Vaso-Motor Disturbances, Cured by Dilating the
Cervix and Curetting,
204
Hysterical Cough with Anteflexion and Dysmenorrhea,
206
·
Reflex Aphonia, Cured by Removal of the Appendages, .
Membranous Enteritis During Climaxis, .
Reflex Asthma, Temporarily Cured by Removal of the Appendages, .
Reflex Asthma of Eighteen Years' Standing, Cured by Removing Prolapsed
Tissue from the Urethra,
Acute Vomiting of Two Years, due to Anteflexion,
Reflex Intestinal Neurosis,
Eczema of the Face, Cured by Perineorrhaphy and Trachelorrhaphy,
206
•
207
208
211
•
2II
211
213
Acne Pustule on the Side of the Nose, Recurring with Each Menstrual Period,. 214
Hystero-neurosis of the Liver, Simulating "Gall-Stones,"
215
Suicidal Melancholia with Retroflexion,.
216
Epilepsy Mitior (petit mal), Cured by Operating upon the Cervix and Perineum, 219
Epilepsy of Six Years' Standing, Greatly Relieved by Removal of the Append-
ages,
220
t
xiv
ILLUSTRATIVE CASES.
XV
PAGE
Epilepsy of Fourteen Years' Duration, Greatly Relieved by Removal of the Ap-
pendages,
221
Epilepsy Greatly Relieved by Divulsing the Cervix and Rectum,
Xanthoxylum in Amenorrhea, .
222
237
Hydrastis Canadensis in Uterine Hemorrhage,
254
Cannabis Indica in Menorrhagia,.
254
Obstinate Menorrhagia, Cured by One Application of the Curette,
·
255
Uterine Hemorrhage, Due to Interstitial Fibroid, Controlled by Curetting,
256
Borax in Membranous Dysmenorrhea, .
275
Platina in Dysmenorrhea, .
275
Viburnum Opulus in Dysmenorrhea, .
276
Cocculus in Dysmenorrhea,
Guaiacum in Chronic Ovaritis with Dysmenorrhea, .
•
Xanthoxylum in Membranous Dysmenorrhea,
Milfoil in Membranous Dysmenorrhea, .
Guaiacum in Spinal Irritation with Ovaritis and Dysmenorrhea, .
Cases Showing the Beneficial Effects of Divulsion in Obstructive Dysmenorrhea, 278
Reflex Nervous Symptoms During the Menopause, Cured by Divulsion and the
Application of Carbolic Acid, .
Dipsomania During Menopause,.
Kleptomania During Menopause,
•
Nervous Aphonia During Menopause,
•
The Menopause Delayed by Fungosities of the Endometrium,
276
277
277
277
278
·
287
288
288
288
289
Diarrhea and Morbid Perspirations During Menopause,
289
Dropsy and Hematuria Attending Pregnancy,
301
Vicarious Hemorrhages from the Stomach, Eyes, and Nose,
•
301
Vicarious Hemorrhages from Strumous Scars, Eyes, Knees, Thighs, etc.,
Vicarious Hemorrhage from the Leg,
301
•
302
Vicarious Leucorrhea,
302
Vicarious Hemorrhage from Lower Lip,
302
Amenorrhea with Vicarious Hemorrhage,
303
Vicarious Hemorrhage from Varicose Ulcers of Leg,
303
Singular Case of Vicarious Hemorrhage,
304
Vicarious Hemorrhage from Hemorrhoidal Tumors of the Rectum,
Vicarious Hemorrhage from a Mole on Forehead,
304
304
•
Vicarious Epistaxis,
Double Hymen,
•
Gonorrheal Vaginitis Giving Rise to Acute Pelvic Inflammation,
Senile or Adhesive Vaginitis Associated with Obstin¹te Dyspepsia,
Senile or Adhesive Vaginitis,
Senile or Adhesive, Associated with Insanity,
305
•
374
383
•
395
396
Eversion of the Cervical Mucous Membrane in a Virgin, Simulating Cervical
Laceration,
396
•
435
Corporeal and Cervical Endometritis, Cured by Galvanism,
457
Areolar Hyperplasia, Cured by Galvanism, .
457
xvi
ILLUSTRATIVE CASES.
Cervical Endometritis, Cured by Galvanism,
PAGE
Pelvic Abscess and Fecal Fistula Following Laparotomy, Cured by Abdominal
Section,
Chronic Metritis of Two Years' Duration. Complete Relief After Three
Applications of Galvanism, .
Chronic Purulent Endometritis of Five Years' Duration. Complete Relief
After Eight Negative Cauterizations,
Chronic Metritis of Five Years' Duration. Uterus Reduced to Normal Size
and Disappearance of Symptoms After Five Applications of Galvanism
to the Cavity, .
458
•
458
458
459
Operation for the Creation of a new Urethra,
Abscess of the Left Ovary and Broad Ligament Following Puerperal Cellulitis
and Peritonitis. Laparotomy. Recovery, . .
Pelvic Abscess Following Hematocele. Laparotomy. Recovery,.
Prolapse of the Mucous and Sub-mucous Tissues of the Urethra,
Removal of a Vesical Calculus through Vagina,
·
Retroflexion Giving Rise to Obstruction of the Right Ureter,.
Retroversion of the Uterus with Procidenția of the Second Degree.
rhaphy and Gastro-hysterorrhaphy. Recovery,
Obstinate Retroflexion of the Uterus with Cystic Degeneration and Prolapse of
the Right Ovary. Gastro-hysterorrhaphy and Salpingo-oöphorectomy.
Recovery,
•
Intractable Dysmenorrhea Following Ovariotomy for the Removal of a large
Ovarian Cyst. Oöphorectomy and Gastro-hysterorrhaphy. Recovery,
Large Myomatous Tumor Springing from Cervix, .
566
489
490
491
•
507
•
•
514
534
555
Perineor-
•
566
•
566
572
Removal of a Large Fibroid together with a Pregnant Uterus. Death,
Large Fibrous Polypus Springing from Cervix,
Diffuse Sarcoma of the Uterine Mucous Membrane. Vaginal Hysterectomy.
Recovery,
611
617
•
657
Carcinoma of the Body of the Uterus. Vaginal Hysterectomy. Recovery, .
Epithelioma of the Cervix. Vaginal Hysterectomy. Death,
Cancer of the Uterus and Annexa. Exploratory Laparotomy. Death,
Ovariotomy for Ruptured Cyst. Recovery,
661
662
676
732
Large Multilocular Ovarian Cyst with Hemorrhage into its Interior. Great
Rapidity of the Pulse Following Operation without Corresponding Rise
in the Temperature. Recovery,
Intra-ligamentary Cyst Dissecting the Peritoneum in Front as Far as the Liver.
Complete Enucleation of Cyst. Death,.
733
733
Large Proliferous Cyst Weighing Forty Pounds. Ovariotomy. Recovery,
Large Fibro-cystic Tumor of the Ovary, with Long Pedicle, Giving Rise to
Enormous Distention of the Abdomen from Ascitic Accumulation. Opera-
tion. Recovery,
•
734
734
Parovarian Cyst Weighing Twenty Pounds. Operation. Recovery, .
Exploratory Incision for Papillomatous Degeneration of Ovaries.
Hemorrhage which was Controlled by Extensive Gauze Packing,
735
Profuse
736
ILLUSTRATIVE CASES.
xvii
Rupture of Tubo-ovarian Cyst While Practising the Bimanual, .
Pyosalpinx, the Result of Gonorrheal Infection. Oöphoro-salpingotomy Followed
by Intestinal Obstruction. Reopening of the Abdomen at the end of Forty-
eight Hours. Recovery,
Pyosalpinx of Right Side with Cystic Degeneration of Ovaries and Retroflexion
of the Uterus. Salpingo-oophorectomy and Gastro-hysterorrhaphy. Re-
covery, .
Hydrosalpinx of Right Side with Cystic Degeneration of Corresponding
Ovary. Interstitial Salpingitis of Left Side with Cirrhotic Degeneration of
Left Ovary. Salpingo-oophorectomy. Recovery, .
Oöphoritis of Twenty Years' Standing. Complete Prostration from Neurasthenia.
Salpingo-Oophorectomy. Recovery,
·
Non-encysted Intra-peritoneal Pregnancy. Operation. Recovery,
Interstitial Pregnancy Rupturing into Uterus. Recovery,
Extra-uterine Pregnancy. Rupture. Death,.
PAGE
747
758
759
760
•
€ 761
•
794
•
798
•
799
•
ii
PLATE
LIST OF ILLUSTRATIONS.
PLATES.
PAGE
7. Dissection of Pelvis from Above (Savage),
I. Schema of the Genital Circulation (Frontispiece).
II. Topographical Relations of the Pelvic Peritoneum and Cellular Tissue,
FIG.
Showing Seats of Exudation in Inflammation,
I. External Genitals (Martin),
2. Dissection of Perineal Region (Savage),
•
3. Superficial Perineal Fascia, Anterior View (Savage),
4. Deeper Fascia of the Female Perineum; Triangular Ligament or Perineal
Septum (Savage),
•
5. Posterior View of Perineal Septum (Savage),
6. Perpendicular Transverse Section of Pelvis (Savage),
8. Perpendicular Section of Pelvis from Below Upward (Savage),
410
32
34
35
37
38
39
40
42
9. The Relations of the Muscular Floor of the Pelvis to the Presentation at
the Last Stage of Labor,
42
10. Median Perpendicular Section of Pelvis (Cazeaux),
44
II. The Pelvic Organs and the Pelvic Cavities from Above (Auvard),
12. Frozen Section, Showing Peritoneum (Furst),
45
46
13. Pubic Termination of Round Ligaments (Savage),
•
48
14. The Pouches and Reflections of the Pelvic Peritoneum (Hodge),
15. Uterus and Annexa,
49
51
16. Coronal Section of the Uterus Through Fallopian Tubes (Savage),
17. Tube, Ovary, and Parovarium (Henle),
18. Vagina in Vertical Section (Hart), .
·
19. Relations of the Ureters at the Level of the Os Internum, as seen from
Above (Polk),..
20. Vesicular or Hydatidiform Mole (Museum R. C. S.),
52
53
•
55
56
75
21. The Harvard Chair,
22. Thomas's-Cusco's Speculum,
78
78
27. Wood's Speculum,
23. Nott's Virgin Speculum,
24. Brewer's Speculum,
25. Brewer's Speculum Used as a Sims's,
26. Goodell's Speculum, .
28. Sims's Speculum,
29. Mundé's Modification of Sims's Speculum,
30. Emmet's Self-retaining Sims's Speculum,
79
79
79
888
80
80
81
81
82
•
xviii
LIST OF ILLUSTRATIONS.
xix
FIG.
•
31. Cleveland's Speculum, .
32. Simon's Specula,
33. Ferguson's Speculum,
34. Bi-valve Rectal Speculum,
35. Williams's Rectal Speculum,
36. Skene's Urethral Speculum,
37. Skene's Urethral Endoscope,
38. Cystoscope of Nitze and Leiter,
39. Simpson's Uterine Sound,
40. Sims's Flexible Probe,
•
41. Long Angular Tenaculum,
42. Nott's Depressor,
•
43. Hank's Hard Rubber Uterine Dilators
44. Wylie's Uterine Dilator,
PAGE
82
82
83
83
84
84
84
85
85
85
86
86
86
86
45. Simon's Spoon Curette,
87
47. Bozeman's Dressing Forceps,
•
46. Thomas's Dull Wire Curette,
48. Junker's Inhaler,
49. Latero-abdominal, or Sims's Posture (Skene),
50. Regions of Abdomen (Edis),
51. Conjoined Manipulation,.
52. Method of Introducing the Uterine Sound (Hart and Barbour),
53. Incorrect Method of turning Uterine Sound (Hart and Barbour),
54. Correct Method of Turning Uterine Sound (Hart and Barbour),
55. Digital Eversion of Rectum (Mundé),
56. Vaginal Irrigator, .
•
57. Tamponnement of the Peritoneum (Pozzi).
58. Bozeman's Reflux Uterine Catheter,
59. Emmet's Curette Forceps,
•
60. Cleveland's Glass Cervical Plug, .
87
88
88
90
95
102
107
108
•
•
108
III
140
179
249
251
270
61. Hypertrophy of the Clitoris (Museum R. C. S.),
322
62. Hypertrophy of External Organs of Generation (Museum R. C. S.),
323
63. Epithelioma of the External Genitalia (Wood),.
340
64. Sims's Vaginal Dilator,
356
65. Imperforate Hymen with Distention of Vagina and Uterus,
368
66. Section of Vagina Showing Cicatricial Bands (Wood),
388
67. Senile or Adhesive Vaginitis (Wood), ·
390
68. Senile or Adhesive Vaginitis (Wood),
69. Cross Section of Pelvis (Luschka),
70. Laceration with Erosion of the Cervix (Martin),
71. Erosion with Enlargement of Follicles (Martin), .
72. Fissured Cervix with Granular Mucous Membrane (Schroeder),
73. Ectropion of the Cervix (Auvard and Devy),
74. Cystic and Papillar Hyperplasia of Cervix (Mundė), .
75. Conoid Cervix, Pinhole Os (Palmer), .
76. Dilated Cervical Canal (Mundé),
77. Intra-peritoneal Hematocele,
392
406
430
430
•
431
432
432
•
453
453
•
466
XX
LIST OF ILLUSTRATIONS.
FIG.
78. Extra-peritoneal Hematocele (Auvard and Devy), .
79. Extra-peritoneal Hematocele (Auvard and Devy),
80. Reflux Catheter (Skene),
PAGE
472
473
500
81. Prolapse of the Mucous and Submucous Tissues of the Urethra (Wood),. 508
82. Self-retaining Catheter (Skene-Goodman), .
83. Sims's Curved Scissors,
84. Bozeman's Straight Scalpel, .
·
85. Method of Paring Edges of Urinary Fistula with Knife (Savage),
86. Method of Paring with Scissors (Savage),
87. Emmet's Needles,
88. Sims's Needle Forceps,
89. Introduction of Sutures,
90. Emmet's Counter Pressure Hook,
91. Sutures Passed,
92. Twisting the Sutures,
93. Sims's Shield,. .
94. Wood's Sponge Holder,
95. Wood's Wire Twister,
96. Removal of Sutures,
•
97. Simon's Position for Vesico-Vaginal Fistula (Simon),
522
524
524
•
525
525
526
•
526
526
526
· 527
•
•
527
528
528
98. Sutures Tied (Simon),. .
99. Operation for Vesico-Vaginal Fistula by Flap-splitting (Walcher),
100. Operation for Vesico-Vaginal Fistula by Flap-splitting (Walcher),
IOI. Variations of the Positions of the Uterus caused by the Various Degrees of
Bladder Distention,
102. Anteversion of the Uterus,
103. Anteflexion of the Uterus (Museum R. C. S.),
104. Graily Hewitt's Anteversion Pessary,
105. Thomas's Anteversion Pessary,
106. Thomas's Open-Cup Anteversion Pessary,
107. Retroversion of the Uterus (Museum R. C. S.),
108. Hodge's Closed Lever Pessary,
•
•
109. Thomas's Retroflexion Pessary,
110. Albert Smith's Retroflexion Pessary,
III. Thomas's Cutter's Retroversion Pessary,
112. Thomas's Cutter's Anteversion Pessary, .
113. Gastro-Hysterorrhaphy (Leopold),
114. Utero-Vaginal Prolapse,
•
•
528
529
·
530
530
531
532
544
•
548
549
552
552
•
553
557
558
558
•
559
561
561
564
568
115. Complete Prolapse of the Bladder, Uterus, and Rectum (Museum R. C. S.), 569
116. Complete Procidentia of the Uterus, Vagina, and Bladder (Wood),.
570
117. Hypertrophic Elongation of the Cervix with Prolapse (Museum R. C .S.), 573
118. Inflated Soft Rubber Pessary,
•
120. Thomas's Cutter's Cup Pessary for Prolapse,
119. Inflated Ball Pessary,
121. Inversion of the Uterus (Auvard and Devy),
123. Inversion of the Third Degree (Auvard and Devy), .
122. An Unimpregnated Inverted Uterus (Museum R. C. S.), .
574
574
574
576
577
578
LIST OF ILLUSTRATIONS.
xxi
FIG.
PAGE
124. White's Uterine Repositor,
•
581
125. Diagram, Showing the Beginning of Fibroma Uteri and Their Mode of
Growth (Auvard and Devy),
584
126. A Uterus in the Walls of which are Eight or Nine Fibroid Tumors
(Museum R. C. S.),
127. A Pregnant Uterus and Large Fibroid Tumor (Museum R. C. S.),
128. A Uterus with Two Large Fibroid Tumors (Museum R. C. S.),
129. Uterus and Annexa with Small Fibroid Tumor (Museum R. C. S.),
130. Fibroid Springing from Posterior Wall of Cervix, .
131. Greenhalgh's Tumor Forceps,
•
132. Tait's Corkscrew for Hysterectomy,
585
586
588
589
•
591
601
604
133. Extra-peritoneal Method of Treating Pedicle (Hegar),
606
134. A Pregnant Uterus Together with a Subserous Fibroid (Wood),
612
135. A Uterus Containing a Fibrous Tumor in the Process of Pediculation
(Museum R. C. S.),
616
138. Vascular Mucous Polypus Growing from Inner Wall of Uterus (Museum
R. C. S.),
136. Submucous Fibrous Polypus Projecting into Vagina (Auvard and Devy), 617
137. Fibrous Polypus Springing from Cervix (Wood), .
617
618
139. Mucous Polypi (Schroeder),
619
140. Enlarged Pediculated Cystic Follicles (Beigel),
619
141. Aveling's Polytome,
623
142. Epithelioma of the Cervix (Museum R. C. S.),
630
143. Medullary Cancer of Cervix Invading the Vagina (Museum R. C. S.), .
•
635
144. Cancer of the Cervix and Vagina (Museum R. C. S.),
636
145. Simon's Retractor,
648
D
146. Lee's Modification of Greig Smith's Broad Ligament Clamp,
649
147. Wood's Needle for Vaginal Hysterectomy,
650
148. Cancer of Uterine Body with Cystic Degeneration of Right Ovary (Wood), 661
149. Diagram of the Structures in and Adjacent to the Broad Ligament
(Doran),.
664
150. Multilocular Ovarian Cyst (Doran),
664
151. Dermoid Cyst (Museum R. C. S.), .
667
152. Papillomatous Disease of the Broad Ligaments (Museum R. C. S.),
669
•
•
153. Parovarian Cyst (Museum R. C. S.),
154. Parovarian Cyst (Museum R. C. S.),
155. Cancer of Uterus and Annexa (Wood),
156. Area of Dulness in Ovarian Cyst,
157. Area of Dulness in Ascites,
158. Position of Tables, Operator, Assistants, etc., During Ovariotomy (Doran), 707
159. Catch Forceps,
160. Elbowed Scissors,
161. Director for Dividing Peritoneum,
162. Emmet's Ovariotomy Trocar,
•
163. Spencer Wells' Ovariotomy Trocar,
164. Wilcox's Cyst Forceps,
165. Spencer Wells' Cyst Forceps,
708
708
709
•
710
710
711
711
670
670
677
•
•
688
688
xxii
LIST OF ILLUSTRATIONS.
FIG.
166. Spencer Wells' T-Forceps,
167. Keith's Ovariotomy Clamp, .
168. Cleveland's Ligature Forceps,
169. Staffordshire Knot,
170. Thomas's Curved Non-perforated Drainage Tube,
171. Thomas's Curved Perforated Drainage Tube,
172. Incomplete Ovariotomy,
173. Lymphatics of Uterus (Poirer), .
174. Hydrosalpinx (Museum R. C. S.), .
175. Tubo-ovarian Cyst (Museum R. C. S.),
176. Tubo-ovarian Cyst (Museum R. C. S.),
177. Double Hydrosalpinx (Beigel),
of Rupture (Tait),
PAGE
712
. 714
· 714
715
. 717
717
.' 721
738
· 744
178. Diagrammatic Section of Fallopian Tube, Representing the Two Directions
179. Ectopic Pregnancy (Museum R. C. S.),
180. Ectopic Pregnancy (Museum R. C. S.),
181. Ectopic Pregnancy (Museum R. C.S.), .
182. Intra-peritoneal Pregnancy (Wood),
745
746
•
747
771
. 777
•
778
779
796
•
183. Bilateral Laceration of Cervix (Skene),
803
184. Multiple Incomplete Laceration of Cervix (Skene),
803
•
185. Area of Denudation in Trachelorrhaphy (Thomas and Mundé),
186. Emmet's Cervical Scissors,
810
811
187. Scott's Uterine Scalpel,
811
188. Introduction of Sutures in Trachelorrhaphy,
812
and Vagina (Kelly),
194. Emmet's Double-curved Scissors,
189. Diagram of Vaginal Outlet, Showing Relations of the Levator, Rectum,
190. Injuries of the Pelvic Floor Shown Diagrammatically (Kelly),
191. Hypertrophic Elongation of Cervix Uteri (Museum R. C. S.),
192. Denudation and Disposition of Sutures in Complete Laceration of Peri-
neum (Emmet), ...
193. Sims's Sharp-curved Scissors,
195. First Step of Perineorrhaphy (Skene),
196. Surface Denuded and Sutures in Position (Thomas),
197. Lines of Incision in Flap-splitting Operation (Mundė),
198. Lines of Incision in Flap-splitting Operation (Mundė),
199. Peaslee's Perineal Needles,
•
•
200. Flap-splitting Operation. Introduction of Sutures (Mundé),
201. Superimposed Diagrams of Fritsch's, Hegar's, Bischoff's, Simon's, and
817
818
821
824
826
826
827
828
Emmet's Operations,
202. Hegar's Operation,
203. Denudation in the Emmet Operation. Sutures Passed (Kelly),
204. Introduction of Sutures in Emmet's Operation. The Vaginal Sutures Tied
(Thomas and Mundė),
•
205. First Step of the Author's Subcutaneous Operation, .
206. Stoltz's Operation for Cystocele (Thomas and Mundé),
830
831
832
833
835
836
837
839
841
844
}
ERRATA.
"9
Page 205, 2d paragraph, 9th line, insert "the saliva” before " escaping.”
Page 262, 3d paragraph, 8th line, read "prospect" for "prospects."
Page 343, 1st paragraph, last word, read "source for "sources. ""
Page 423, 3d paragraph, last line, read "afforded" for "offered."
Page 450, 4th paragraph, 3d line, read "may" for "will."
Page 468, 4th paragraph, 4th line, read "region" for "regions."
Page 469, 2d paragraph, 5th line, read "inflammation " for "inflammatory symptoms."
Page 472, 1st line, read " intra-peritoneal" for "intra-uterine."
Page 612, 1st paragraph, 3d line, read "ten" for "two."
Page 615, chapter heading, read "uterine fibromata" for " uterine fibroma."
Page 628, 3d paragraph, 2d line, read "twenty" for “ puberty."
Page 628, last paragraph, 3d line, strike out "per cent."
Page 633, 4th paragraph, 2d line, read "are present" for "is present."
Page 698, 6th paragraph, 5th line, read “suppurative" for "suppurating."
Page 720, 1st paragraph, 3d line, read “she” for “the patient.”
Page 720, 4th paragraph, last line, read "resort to both drainage of the cyst and
abdominal drainage."
Page 748, 3d paragraph, 3d line, omit the word "purulent."
Page 817, 6th paragraph, 4th line, read "it" for "the injury.”
xxiii
A TEXT-BOOK
OF

GYNECOLOGY.
CHAPTER I.
THE CAUSES OF GYNECOLOGICAL DISEASES.
Until our knowledge of pathology shall have become more
accurate, no classification of the DISEASES OF WOMEN can be
perfect. With the full consciousness of this fact I offer the
following:-
ETIOLOGY OF GYNECOLOGICAL DISEASES.
I. Congenital.
(a) Inherited feebleness of constitution;
(b) Defects in or absence of development.
II. Acquired.
(a) Acquired feebleness of constitution ;
(b) Reflex functional disturbance and nervous disorders;
(c) Development of new growths and malignant disease;
(d) Uterine displacements.
III. Inflammatory.
(a) Cellulitis ;
(b) Peritonitis;
(c) Metritis, ovaritis, salpingitis, cystitis, etc.
2
17
18
A TEXT-BOOK OF GYNECOLOGY.
IV. Accidental.
(a) Injuries resulting from pregnancy and parturition—
I. Lacerations and cicatricial deposits;
2. Relaxations of the pelvic floor;
3. Uterine inversion;
4. Fistulæ, sloughing, closure of the os uteri, vagina,
etc.;
5. Ectopic pregnancy;
6. Abortions;
(b) Hematocele.
Inherited Feebleness of Constitution.-As a race, the Amer-
icans are essentially a nervous people. Quiet and recreation
are unknown to the great majority of our population. The
growth and development of a new country and the almost
insane desire to amass wealth, afford the average American but
little time for relaxation and enjoyment. Added to this, our
peculiar climate stimulates the nervous system to an injurious.
degree, and at the expense of nutrition. That our climate exerts
a potent and harmful influence upon the nervous system there can
be no doubt. Europeans, as is well known, cannot perform
the same amount of mental work here as in their native country
without paying the penalty. The researches of archæologists
show conclusively that races now extinct have inhabited this
hemisphere, and it is not unreasonable to believe that climate.
has had much to do with the decay of these races.
Unfortunately the husband is not the only victim in this war-
fare of American civilization. He cannot, or does not, close his
office door and lock his business behind. His wife and family
participate in his anxieties and ambitions. As he ascends in the
financial scale, new social obligations and demands force them-
selves upon them. If reverses come, the mental worry and
distress are still more injurious than the excitement incident to
success. A child born under these circumstances is the inevitable
victim of them. If the parents have inherited a constitution
free from bias or disease the ante-natal influences may be over-
come in after life; if, on the contrary, the parental impression is
derived from organisms feeble and diseased, the offspring suffers
THE CAUSES OF GYNECOLOGICAL DISEASES.
19
from the inexorable law of heredity. With a girl the odds will
be against her from birth to the grave. Climate, social customs
and education, unless her guardians are wiser than their age,
will combine to stimulate her nervous system at the expense of
her physical, and leave her ill-fitted to meet the demands of
puberty, maternity, and the climacteric.
Defects in or Absence of Development.-Under this head
come the various anomalies of development with which the
gynecologist every now and then meets and which are dealt
with in detail in another chapter. Such anomalies are clefts of
the urethra; double vagina with single or double uterus; arrest
of uterine growth in embryo with or without a corresponding
arrest of the ovaries; defects in the shape of the vagina and
cervix; imperviousness of the hymen; entire absence of the
vagina and the uterus; and distortions of the clitoris.
The development of the uterus is probably much more influ-
enced by the growth of the ovaries than are the ovaries by the
uterus, so that after the ovaries reach a certain degree of develop-
ment the further growth of the uterus is dependent upon them.
(Emmet.) Unless the ovaries are sufficiently developed to per-
mit of ovulation, the uterus is not properly stimulated, and an
arrest of growth may occur at any time before this organ is
fully developed. Later in life, our knowledge of the influence
exerted by the ovaries or, according to Lawson Tait, the tubes
as well, enables us to arrest hemorrhage and the growth of
fibroids by their removal.
Acquired Feebleness of Constitution.-The life of woman,
more than of man, is characterized by metaphorical or develop-
mental epochs, during which an unusual predominance is
usually acquired by one or by several of the organs which, in
their totality, make up the human body. These several epochs
mark the transition of the neutral child into the woman, of the
woman into the mother, and finally, when she has fulfilled her
mission of child-bearing, of the mother into mature old age.
With the exception of certain catarrhal diseases, the sexual
*
* An Introductory Lecture on the Diseases of Women. By James C. Wood,
Medical Counselor, Vol. 10, p. 472.
20
A TEXT-BOOK OF GYNECOLOGY.
organs of the girl before puberty are rarely if ever the seat of
disease. So far as physical functions are concerned there is very
little difference between the boy and the girl until the sexual
faculties begin to assert themselves. As puberty approaches,
however, there is the most remarkable difference in the constitu-
tional sympathies of the opposite sexes. The sexual organs in
the one play a comparatively subordinate part in the rôle of re-
production; in the other the utero-ovarian functions are con-
nected with every vital action from the evolution of puberty
until the climacteric period, which terminates a distinctly sexual
or reproductive life. (Ludlam.)
The causes of acquired feebleness of constitution may be
enumerated as follows:
I. Deficient air and exercise;
2. Improper dress;
3. Exposure during menstruation;
4. Improper care during and after parturition;
5. Prolonged and undue emotional stimulation;
6. Marital irregularities.
Deficient Air and Exercise.-The standard of health
depends in no small degree upon the social stratum into which
a girl is born or circumstances in after life may carry her.
The imperious Goddess of Fashion demands a fair face and
fair hands, two things incompatible with fresh air and proper
exercise. The young girl as she approaches her teens is pro-
hibited from taking the requisite amount of exercise because it
is not genteel. If out-door sports are permitted they are not of
such a character as to develop her physical system. As a result
she passes into womanhood poorly fitted for the responsibilities
which maternity will impose upon her. The birth of her first
child often leaves her an invalid, if, indeed, some form of local
disease superinduced before marriage, has not made her sterile.
Improper Dress.--Corsets, low-necked dresses, and high-
heeled shoes are responsible for much mischief and much of
the business of the gynecologist. The short dress is discarded
by far too early, and she who should remain a rollicking girl
casts off her shoulder straps and constricts her waist with strings
THE CAUSES OF GYNECOLOGICAL DISEASES.
21
and bands, thus crowding the abdominal organs into the pelvis.
(Emmet.) As a result, the function of respiration is interfered
with, the pelvic organs become displaced, the abdominal muscles
atrophy, and freedom of movement is restricted. The lower
extremities are at no time properly protected, and in evening
dress the chest is likewise exposed. Add to this the injurious
effects of high-heeled shoes,* and the fashionable woman of the
period will do well if she escapes the penalty so often produced
by causes constantly at work. Prevailing fashions and common
customs, therefore, exert a most potent influence for good or for
evil. Unfortunately there is an aping of the higher classes
by the lower, and the evils of dress are therefore seen in every
sphere of life and grade of society. We thus see that modifica-
tion of form, disturbance of the functions of special organs, and
alteration of single parts depend in no small degree upon the
habit of dress.
Exposure During Menstruation.-There is no physiological
function imposed upon the female organism which is so liable
to become pathological as is menstruation. This is not as it
should be, yet it is in keeping with the refining and depressing
influences of modern civilization. Menstruation should be as
painless and as normal as defecation; and so we find it as we
descend in the scale of evolution. The Indian girl, and, we are
told, the negress in her native abode, do not suffer in the least,
notwithstanding the fact that at all times they are subjected to
the most severe exposure and exercise. Their systems have
become inured to hardships by the environs, which have exerted
a hardening influence, not only upon them, but upon their
ancestors through countless generations. Indeed, evidence is
to be had proving that the menstrual discharge was absent in
their ancestors; that it developed with time because of a failure
to gratify the reproductive instinct, and then became a habit.
(Roussel, Auber.) Whether this statement be true or false, the
influence of hard work and simple fare upon the quantity of
hemorrhage is incontestable. The girl or woman reared prop-
erly and endowed with a constitution such as she is entitled to
* Gynecological Transactions, Vol. 7, p. 243.
22
A TEXT-BOOK OF GYNECOLOGY.
as a birthright, can stand exposure during menstruation which
would be decidedly hazardous to her more delicate sister.
It is but a step from physiological to pathological congestion,
and the next succession in the train of pathology is inflamma-
tion. At each menstrual period a physiological congestion
occurs, and in the great majority of women is associated with
phenomena due to disturbed innervation and circulation. The
system is in a susceptible state, and the congestion and irritation
may extend to various parts of the body. If, either through
necessity or recklessness, a menstruating woman goes lightly
or improperly clad during the most inclement weather, the seeds
of permanent disorder may be sown. The inflammatory dis-
eases frequently originate in this way; oftener a serious dysmen-
orrhea dates from such exposure. Certainly ordinary prudence
suggests that during a time when all of the pelvic organs are
intensely engorged, when the escaping ovule from the ovary has
broken its surface, the woman should observe at least reason-
able precaution. Nevertheless menstruation does not keep the
average girl from the ball-room, even though it has to be sup-
pressed by artificial means. To her the pleasures and conquests
of a night are of greater importance than future health and
happiness. Parenchymatous disease often follows an inflamma-
tion thus excited, resulting in sterility and menstrual disorders
which, acting through the sympathetic system, influence and
deprave nutrition.
Improper Care During and after Parturition.-Uterine
contractions, from the very onset of labor, have a physiological
mission other than the expulsion of the child. They consume
the cell-elements of the enlarged uterus, and by compressing
the nutrient vessels deprive them of oxidized protoplasm, which
inaugurates fatty degeneration. These contractions continue
even after the uterus is emptied, and give rise to the so-called
after-pains." The protein substances resulting from the de-
generation of the muscular fibers are converted into fats, which
are absorbed. Eventually new cells appear upon the external
layer of the uterus, from which a new organ is developed.
(Schroeder.) With the growth of new cells the old and enorm-
ously enlarged ones of pregnancy entirely disappear. In the
THE CAUSES OF GYNECOLOGICAL DISEASES.
23
course of six weeks the uterus becomes normal in dimensions
and weight, although remaining somewhat larger and more
rounded than in nulliparæ. (Spiegelberg.) This process is
called involution, upon the proper performance of which the
woman's future health in no small degree depends.
The phenomena appertaining to involution and to the puerpe-
cal state would, under different circumstances, be considered
pathological. Associated with the degeneration of muscular
cells, thrombi are formed in the enlarged and torn vessels and
the decidua is exfoliated. The size of the lymphatics is also
exaggerated, which, together with the traumatism almost never
absent, predisposes to septicemia, cellulitis, the formation of
emboli, etc. These effects are immediate and must be dealt with
accordingly. The remoter and more permanent ones have to do
with perfect involution, which is only insured by proper care dur-
ing the lying-in period. Uncleanliness during and after labor,
and dragging the placenta from the uterus instead of expressing
it by the more scientific method of Credè, are responsible for much
that follows; failure to close rents and torn surfaces is equally
reprehensible; and the prescribed nine days for "getting up" is
a relic of the dark ages. Every woman is a law unto herself and
should be so considered; what one may do with impunity may
be the death of another. The size of the uterus, the persist-
ence of the lochia, and the strength of the patient are the only
scientific guides by which to gauge the period of absolute rest
in bed. So long as the parturient womb can be felt above the
pubes, by external examination, just so long is it unwise and
unsafe for her to assume the erect posture. The increased
weight will cause it to descend, thus interfering with the pelvic
circulation, which, in turn, gives rise to congestion or inflamma-
tion and often to permanent uterine displacement. The time
is not far distant when the physician's success as an accoucheur
will be judged, not by the length of time during which he keeps
his patient at rest, but by the completeness of her recovery.
The mammæ and uterus are sympathetically and almost
mysteriously connected. This connection is one of the most
useful designs of nature, and through it uterine involution is
promoted. The application of the child to the breast excites
24
A TEXT-BOOK OF GYNECOLOGY.
uterine contraction, and if this stimulation is withheld involution
is apt to be incomplete. In the upper circles there is a tendency
to relegate babes to wet-nurses and rubber nipples, and nature
imposes her penalty for so doing. The system is soon taxed
with the menstrual function, which should remain dormant for
at least twelve months after confinement. Unless subterfuges,
far more injurious than pregnancy itself, are resorted to, concep-
tion is liable to occur before the system has fully recovered from
the previous labor. From a purely physiological standpoint,
every mother should nurse her child unless insuperable obstacles
prevent; if it seems unwise to continue lactation during the
usual period, it should at least be continued while involution is
going on, if the counter-indications are not imperative.
It will be seen that the best means of securing and promoting
uterine contraction are vital and not mechanical. What is true
of the uterus is also true of the over-stretched abdominal
muscles and their coverings. The comeliness of the figure can-
not be regained or preserved by a tight bandage-the curse of
the lying-in chamber. Healthy muscles, whose function it is to
contract under the command of the will, were never made
stronger by non-use. The abdominal muscles are no exception
to this rule, and if their movements are restricted by tight
bandaging, atrophy is apt to result. Again, a bandage im-
properly applied over an unnatural compress, forces the enlarged
uterus into the pelvis and backward, causing a temporary if not
a permanent displacement. This more often results if the
dorsal posture is persistently maintained instead of permitting
that position which is the most comfortable. When abdominal
distention has been very great, and a moderately tight bandage
affords a sense of relief, there can be no objection to applying it
for a few hours or a few days; however, the practice of com-
pressing the abdominal and pelvic organs for days and even
weeks is not only the result of an exploded superstition but an
actual injury.
Reflex Functional Disturbance and Nervous Disorders.—
The ganglionic system of nerves in women is more developed
than in man, the great centre being the solar plexus. The gen-
erative organs are surrounded by a reticulation of blood-vessels,
THE CAUSES OF GYNECOLOGICAL DISEASES.
25
the smallest capillaries of which are in intimate contact with
sympathetic nerve filaments. Each ganglion is in direct com-
munication with the cerebro-spinal system through the spinal
filaments which enter it. These two great nervous systems,
though each is complete in itself, are, nevertheless, dependent
one upon the other. They should work harmoniously together,
and so they do if unmolested. An afferent impulse starting
from the reproductive organs will induce, through the central
nervous system, vaso-motor changes which will affect the pelvic
circulation either favorably or unfavorably. (Foster.) It is in this
way that many reflex phenomena are induced. When normally
exerted, the influence of the sympathetic system on nutrition is
a healthy stimulus to organic life. If, on the other hand, the
stimulus becomes impaired, owing to local disease or irritation,
reflex functional disturbance in some part of the body at once
ensues. The morbid impression received by the sympathetic
system is transmitted through the spinal nerves to the brain,
which, in turn, transmits it to the special ganglion of the affected
organ. The spinal nerve passing from this ganglion will convey
pain to the seat of its distribution. (v. Chapter VIII.)
These physiological facts, briefly stated, explain many symp-
toms occurring in women which would otherwise remain enigmas.
The extent of the reflex mischief produced by a local lesion
depends less upon the nature of the lesion than upon the con-
dition of the cerebro-spinal system. Every practitioner has met
with many instances where women have gone for years with
uterine displacements, cervical lacerations, etc., without the
least inconvenience. In others, the slightest local disturbance
may impress the system in the most profound manner. If lack
of moral restraint and training, faulty education or, possibly,
mental shock, has rendered the brain morbidly sensitive, the
disturbance created by the organs of generation will fall with
crushing force upon the cerebro-spinal system. Insomnia,
hysteria, and even insanity result in this way; and pain in any
and every part of the body may have its origin in the pelvis.
Conversely, lesions in other parts of the body may react upon
the generative organs. If there be a due proportion existing
between the development of the nervous system and the
26
A TEXT-BOOK OF GYNECOLOGY.
muscular, the equilibrium is not readily disturbed and local dis-
orders may cause little or no impression. (Emmet.)
With this knowledge of cause and effect as related to the
diseases of women, the importance of preventing or removing
the former before the latter can be reached is self-evident. It
involves our system of education, which tends to create large
brains and small bodies. The stimulation of the emotional
faculties by improper literature is responsible for much mischief.
No provision is made for the demands of approaching puberty—
not the slightest relaxation from study or mental work. Co-
education stimulates the girl to equal if not to excel her boy
associates, upon whom nature imposes no physiological barriers
in the form of menstruation; or, ill-governed and wretchedly
ventilated boarding schools furnish a more superficial education
at the expense of quite as much wear and tear of the nervous
system. *
The result is the same in either instance. Too often
the girl exchanges a good constitution for a meaningless
diploma. She is ill-fitted to become a wife and loath to assume
the duties and responsibilities of maternity. She is advised to
shirk the latter, and "conjugal onanism" is resorted to. Expe-
dients and paraphernalia borrowed from the brothel are brought
into requisition, and the marital couch is thus defiled. Should
conception occur, men of "båttered reputations” stand ready
on every hand to commit infant murder. (Goodell.) An im-
perious instinct is denied gratification when the responsibilities
of motherhood are shirked. As a result, the pelvic organs are
left congested and the nervous excitement unappeased. Inflam-
mation of the uterus and appendages with displacement and
erosions are the inevitable sequelæ. The marriage relations
bring pain instead of pleasure, and the mental distraction
resulting therefrom is the cause of more than one separation
* Let the reader remember that this chapter is devoted to the causes of gyneco-
logical diseases. My long connection with the largest co-educational institution in
the world leads me to speak with much emphasis. Nevertheless, I am not blind to
the fact that the evils of existing systems leave their impress, to a greater or less
extent, upon both sexes. I am a thorough believer in co-education. However, it
should and can be inseparably associated with a system of physical culture which
will develop brain and body simultaneously.
J. C. W.
THE CAUSES OF GYNECOLOGICAL DISEASES.
27
and divorce. I am not a pessimist, but a chapter devoted to
the etiology of the diseases of women would be incomplete
without touching upon an evil as insidious as it is far reaching.
Development of New Growths and Malignant Disease.-
We possess but little or no definite knowledge bearing upon the
causation of most neoplasms, and particularly of those attacking
the uterus. (Gusserow.) Virchow, Winckel, Cohnheim, Emmet
and many others have put forth theories, all of which are
imperfect. We are able to study the circumstances under which
new formations develop; beyond this point we have not, up to
the present time, succeeded in going. These include environs,
nutrition, habits, age, race, state, etc. The commencement of
many diseases, like the essence of life and death, as yet remain
impenetrable.
•
The above circumstances as causative factors will be
studied in other chapters. I shall, at this time, but briefly
allude to the theory of congestion and hypertrophy so ably
championed by Emmet, because it bears directly upon much
that has already been said. According to this author, any
cause that will keep up a more or less persistent congestion of
the uterus will in due time excite a congestive hypertrophy of
this organ; that, as a result, the nutrition of the parts becomes
faulty and exaggerated; and as a consequence of this faulty
nutrition, new growths originate, in the form of fibroma. Or,
when the ovaries cease to perform their function, nutrition is
diverted from the pelvis to other parts of the body, with resulting
fatty degeneration of the uterus. Nutrition is now no longer
occupied in the formation of new structures but in the removal
of old. If some previous injury exists, it may be misdirected
in its efforts to remove the products of such injury (hyperplasia,
cicatricial tissue, etc.) and a neoplasm develops, frequently an
epithelioma. Reasoning from analogy, this theory is the most
plausible of any yet promulgated. It involves much pertaining
to the habits of life which have already been discussed.
Uterine Displacements.-Uterine displacements may be
congenital as well as acquired. The congenital displacements
are usually associated with some defect in the development of
the organ, and the only bad symptoms resulting therefrom are
28
A TEXT-BOOK OF GYNECOLOGY.
connected with the menstrual function and with generation.
The acquired forms result from accident, congestion, inflam-
mation, pregnancy, etc., and cause more or less local and general
distress, depending upon circumstances. It is probable that the
mere malposition of the uterus gives rise to but little if any
suffering, unless the displacement is the result of accident, but
that the suffering is due to secondary changes within the uterus
and the pelvis. Such changes are congestion, chronic inflam-
mation, hyperplasia, and displacement of the ovaries, all of
which often excite reflex phenomena of the most distressing
character. Disorders of the rectum and the bladder are likewise
frequently due to uterine displacements.
Inflammatory: Accidental.-The inflammatory and acci-
dental causes do not demand at this time seriatim consideration.
There is nothing obscure about them and since, as causative
factors, they are recognized by all authorities, I will briefly
present only a few general considerations.
Salpingitis and the diseases of the Fallopian tubes have
attracted much and wide attention during the last ten years.
That the ovaries and tubes are responsible for much mischief,
I am certain; and that many normal or curable ovaries and
tubes have been sacrificed by over-zealous operators, I am even
more certain. Unalloyed good rarely results from bold innova-
tions made by men like Battey, Tait, and Heger. Operators
with a reputation to make require material, and inexperienced
diagnosticians too often ascribe obscure pelvic affections to the
uterine appendages, which are accordingly removed. It is well
that some of the older men have raised a protesting voice, for a
beneficent operation is liable to fall into disrepute when per-
formed with unwarranted frequency.
The injuries resulting from pregnancy and parturition are
countless. The more serious rents, uterine inversion, fistulæ, and
adhesions force themselves upon the attention of all physicians.
Cicatrices and relaxations of the pelvic floor, on the contrary,
have not as yet received the attention which they deserve. In
England and on the continent but a comparatively small number
of specialists resort to Emmet's operation, or trachelorrhaphy,
and those who do perform it have not mastered the originator's
THE CAUSES OF GYNECOLOGICAL DISEASES.
29
technique. What is true of the cervix is also true of the perin-
eum and pelvic floor. It will require another decade before the
profession, as a whole, will have learned sufficient of cause and
effect fully to comprehend the significance of the more obscure
injuries within the pelvis.
This brief survey of THE ETIOLOGY OF GYNECOLOGICAL
DISEASES Shows conclusively, I think, the importance of the
subject. Woman is subjected to those general diseases attack-
ing both sexes indiscriminately; she is also a victim of causes,
many of which are avoidable, to be sure, but many of which
she cannot escape. Specialists will, therefore, ever be in
demand; and the day is long past when the general practitioner
can successfully "get on" with a mere smattering of gyne-
cology.
CHAPTER II.
THE ANATOMY OF THE FEMALE PELVIC
ORGANS.
EMBRYOLOGY.
I deem it unnecessary in a practical text-book on gynecology
to discuss at length the subject of embryology. It is one
belonging to obstetrics rather than gynecology. The following
schema, prepared for my class in obstetrics, shows the success-
ive steps in the early development of the ovum and the struct-
ures from which various organs are derived. It will, therefore,
prove useful in explaining some of the anomalies of develop-
ment with which the gynecologist has to contend. The four
layers formed by the blastodermic vesicle, viz., the ectoderm, two
strata of mesoderm, and entoderm, are supposed to have the
relations to the ulterior development of the body indicated in
the schema, though some points bearing upon the subject are as
yet unsettled.
DEVELOPMENT OF THE OVUM, SHOWING SUCCESSIVE CHANGES
FOLLOWING FECUNDATION.
1. Contact of spermatozoa with ovum, probably in the Fallopian Tube.
2. Disappearance of germinative vesicle.
3. Segmentation forming morula.
4. Changes in MORULA-formation of blastodermic vesicle.
5. BLASTO-
I. Ectoderm-developing hair, nails, glandular structure of skin;
the brain, spinal cord, organs of special sense, and
genito-urinary organs.
DERMIC
VESICLE
FORMS.
II. Mesoderm.—
【 (a.) OUTER STRATUM-developing corium, mus-
cles of trunk, and bony
framework.
(6.) INNER STRATUM-developing muscular and
fibrous tissue of digestive
tract, the blood, blood-
vessels, and blood-glands.
III. Entoderm-developing epithelium lining walls and glands of
intestine.
}
Sembryonic spot.
6. AREA GERMINATIVA, composed of {(a.) area pellucida, in which appears the
7. EMBRYONIC SPOT-bisected by primitive trace.
30
THE ANATOMY OF THE FEMALE PELVIC ORGANS.
33
organs the labia minora are always in contact, as are the inner
surfaces of the labia majora, except when the knees are widely
separated.
MUSCLES OF THE FEMALE PERINEUM.
The Perineal Body (Fig. 2, P) is a pyramidal, wedge-shaped
body occupying the space midway between the anus and the pos-
terior vulvar commissure. It is the center of attachment for the
transversus perinei muscle; the anterior end of the superficial
sphincter muscle; the ligamentum ischio perinei-formed by
the union of the superficial perineal fascia with the inferior border
of the perineal septum ; the median fibers of the bulbo-cavernosus
muscle; the perineal septum below the vagina; and the inner
median fibers of the levator ani muscle.
By a great accession of elastic tissue these several structures
are fused together without altogether losing their identity, thus
forming the perineal body. It measures 1½ inches vertically,
the same transversely, and 3/4 of an inch antero-posteriorly.
(Hart.)
The Perineal Muscles are three in number on each side of
the vaginal orifice, the transversus perinei (Fig. 2, 7), the bulbo-
cavernosus (Fig. 2, 5), and the erector clitoridis (Fig. 2, 4).
The Transversus Perinei arises from the ramus of the
ischium and from the anterior aponeurosis of the perineal
septum, and is inserted into the perineal body.
The Bulbo-cavernosus (Fig. 2, 5) arises below from the
perineal body and from the anterior aponeurosis of the perineal
septum. It passes forward partially covering the bulb of the
vagina, and is inserted into the corpus cavernosum of the clitoris,
the posterior surface of the bulb and the mucous membrane
between the clitoris and urethral orifice. (Henle.)
The Erector Clitoridis (Fig. 2, 4) arises from the ramus of
the pubis and the ischium and is inserted into the back and sides
of the crus clitoridis.
The Bulbi Vagina (corpora spongiosa urethra) lie on each
side of the vaginal orifice resting on the triangular ligament and
partly covered by the bulbo-cavernosus muscle. They consist
3

34
A TEXT-BOOK OF GYNECOLOGY.
of masses of erectile tissue about 3/4 of an inch long, and
anteriorly each blends with its fellow, this pars intermedia
becoming continuous with the clitoris (Fig. 2, B).
FIG. 2.
S
ģ
C
DISSECTION OF PERINEAL REGION. (Savage.)
A. Anus; B. Bulb of vagina; C. Coccyx; L. Large sacro-sciatic ligament; P.
Perineal body; v. Vaginal aperture; U. Orifice of urethra; g. Vulvo-vaginal
glands. 1. Clitoris; 2. Its suspensory ligament; 3. Crura clitoridis; 4. Erector
clitoridis muscle; 5. Bulbo-cavernosus muscle; 7. Transversus perinei muscle;
8. Sphincter ani externus; 9. Levator ani.
The Vulvo-vaginal Glands (Bartholinian glands) lie in front
of the posterior layer of the triangular ligament and close to the
posterior end of the bulbi vaginæ. Each opens by a long duct
at the sides of the hymen. (Fig. 2, g.)

THE ANATOMY OF THE FEMALE PELVIC ORGANS.
35
THE FASCIAE OF THE PELVIC FLOOR.
The Superficial Fascia of the pelvic floor consists of two
layers-an upper one, which lies beneath the skin, more or less
loaded with fat and is the continuation over the pelvic floor of
FIG. 3.
n
SUPERFICIAL PERINEAL FASCIA; ANTERIOR VIEW. (Savage.)
A. Anus; M. Urethral meatus and urethro-vaginal tubercle; H. Nymphæ; C.
Clitoris; T. Tuberosity of ischium; c. Levator ani muscle; a. Anterior edge
of gluteus maximus muscle; n. Neck of pudendal sac; O. Pudendal sac.
the same structure which covers the abdomen, nates, and thighs;
an under one, or deep layer, which forms a resisting membranous
investment. The deep layer of the superficial fascia descends
36
A TEXT-BOOK OF GYNECOLOGY.
from the abdomen over the pubis and covers the anterior peri-
neal triangle down to its base, becoming attached to the outer
margins of the ischio-pubic rami and to the lower margin of the
septum or triangular ligament.
The Pudendal Sac (Fig. 3, O) commences at the margin of
the external inguinal ring and is formed by the deep layer of
superficial fascia and the outer layer of the triangular ligament.
It receives at its neck (n) the terminal fibers of the round
ligament of the uterus. These sacs, one on each side of the
vaginal orifice, usually contain more or less fatty tissue, and
with their cutaneous coverings present themselves at the vulva
as the labia majora. Inguinal hernias readily find their way
into them and are then known as labial hernias.
DEEPER FASCIAE.
The Ischio-perineal ligament is formed by the union of the
deep layer of superficial fascia with the lower border of the
perineal septum. It is attached by its outer end to the ramus of
the ischium and blends insensibly with other structures in the
perineal body.
The Perineal Fascia enclose the following structures from
without inward :—
Between the Skin and Superficial Fascia: Superficial peri-
neal arteries and nerves; superficial hemorrhoidal vessels and
nerves.
Between the Deep Layer of Superficial Fascia and Anterior
Layer of Triangular Ligament: Erector clitoridis; bulbo-
cavernosus; transversus perinei; bulbs of the vagina; pu-
dendal sacs; transverse perineal blood-vessels and nerves;
venous plexuses; dorsal artery, and vein of clitoris.
Between the Layers of Triangular Ligament: Urethra-
in part; compressor urethræ; vagina-in part; pudic vessels.
and nerves.

THE ANATOMY OF THE FEMALE PELVIC ORGANS.
37
FIG. 4.
DEEPER FASCIA OF THE FEMALE PERINEUM (TRIANGULAR LIGAMENT OR
PERINEAL SEPTUM). (Savage.)
a. Gluteus maximus muscle; L. Large sacro-sciatic ligament; T. Tuber ischii; c.
Levator ani muscle; A. Anus, surrounded by b, Sphincter externus; d e,
Transversus perinei and bulbo-cavernosus muscles crossed by a branch of pudic
vein; both muscles partially removed to anterior aponeuroses of the perineal
septum, m, and membranous investment of the bulb, 1; g. Anterior (lower)
portion of Erector clitoridis muscle; n. Aponeurotic expansion of the upper
portion on the crus; C. Clitoris and its musculo-membranous covering; M. Ure-
thral meatus; v. Vaginal aperture; f. Muscular fibers belonging to perineal
septum; 1. Bulb partially cut away.

38
A TEXT-BOOK OF GYNECOLOGY.
THE PERINEAL SEPTUM, OR TRIANGULAR LIGAMENT.
Note the Following Points.-The triangular ligament, or peri-
neal septum, fills in the pubic arch and consists simply of two
layers of fascia. These are termed anterior and posterior. They
FIG. 5.
U
3-
2
7
S
P
5
PERINEAL SEPTUM, POSTERIOR VIEW, TOGETHER WITH THE PELVIC ATTACH-
MENTS OF THE LEVATOR ANI MUSCLE. (Savage.)
S. Inner surface of pubic symphysis; U. Urethra; V. vagina; 1. Pubic attachment of
bladder; 2, 3. Pubic attachments of levator ani; 4. Pudic vein; 5. Urethro-
pudal venous plexus; 6. Posterior face of the septum; 7. Median portion of
levator ani, some of its inner fibers passing inward under the vagina, where, with
the lower edge of the septum, they are comprehended in the perineal body.
are attached externally to the greater part of the osseous margin
of the pubic arch extending from the sub-pubic ligament in
front to the beginning of the ischial tuberosity posteriorly. The
upper fibers join those of the opposite side, so as to inclose the

THE ANATOMY OF THE FEMALE PELVIC ORGANS.
urethra. (Fig. 5, U.).
39
The lower fibers join those from the opposite
side, below the vagina. The remainder of the septum resembles
the coats of the vagina. In the reparation of injuries of the
pelvic floor the triangular ligament plays a very important role.
In Fig. 6 the pelvic fascia and their function are clearly shown
by a perpendicular transverse section.
1
FIG. 6.
b
2 Pm4 s3
PERPENDICULAR TRANSVERSE SECTION OF PELVIS THROUGH THE MIDDLE OF
THE VAGINA. (Savage.)
V. Vagina and its posterior column; O. Ischio-rectal fossa, filled with fatty process
of superficial perineal fascia; I. Ischial tuberosity, section of; b. Inferior pelvic
space; d. Recto-vesical layer of pelvic fascia; e. Inferior or perineal layer
of levator ani fascia; n. Obturator fascia; p. Posterior aponeurosis of peri-
neal septum; m. Anterior aponeurosis of same; s. Deep layer of superficial
perineal fascia covered by fatty superficial layer; 1. Cross section of right
crus clitoridis, including erector muscle; 2. Superficial transverse perineal mus-
cle; 3. Bulb of vagina; 4. Muscle of perineal septum.
THE PELVIC FLOOR DISSECTED FROM ABOVE.
In Fig. 7 the Pelvic Floor is seen from above, showing its
internal concave or peritoneal aspect. The peritoneum and
underlying connective tissue is removed, together with the nerves
and blood-vessels, exposing the so-called diaphragmatic muscles
of the pelvis, viz.: the levator ani and the coccygeal. These

40
A TEXT-BOOK OF GYNECOLOGY.
muscles, together with their investing fascia, form by all odds the
most important support of the pelvic floor.
The Levator Ani (2, 3, and 5, Fig. 7) has an extensive origin
(the pubo-coccygeal and obturator coccygeal muscles of Savage). It
arises from the posterior aspect of the pubis near the symphysis
FIG. 7-
2.
8
3
C
5-
P
B
G
7
-7
S
A
R
-8
DISSECTION OF PELVIS FROM ABOVE. (Savage.)
B. Neck of bladder; P. Symphysis pubis; V. Vagina; R. Rectum; C. Coccyx; S.
Sacrum; A. Acetabulum; 1. Anterior vesical ligaments; 2, 3. Levator ani; 4.
Ilio-pubic line of the latter; 5. Coccygeal muscle; 7. Pyriformis muscle; 8.
Obturator muscle.
in front, from the posterior surface of the ischial spine behind,
and between these points from the "white line" of the pelvic
fascia (Fig. 7, 4). From these attachments it sweeps downward
and inward to become firmly attached to the walls of the vagina
and the rectum and to the tip of the coccyx. Between the tip
THE ANATOMY OF THE FEMALE PELVIC ORGANS.
41
of the coccyx and the rectum it blends with its fellow of the
opposite side at the raphé. The series of fibers turning be-
neath the rectum and vagina, intermixing with the lower circular
fibers, form the "internal sphincter" and the “retractor vaginæ."
(Luschka).
The Coccygeal Muscles (Fig. 7, 5) one on each side of the
pelvis, take their origin from the spine of the ischium. They pass
inward, gradually expand into broad, thin laminæ, which are
inserted into the lateral borders of the lower segment of the
sacrum and to the sides and front of the coccyx.
FASCIAL Coverings of the MUSCLES OF THE PELVIC FLOOR.
The Pelvic Fascia, as viewed from above, is attached ante-
riorly near the lower border of the symphysis pubis; laterally
to the pelvic bone; and posteriorly to the spine of the ischium.
At and between these attachments it follows the origin of the
obturator muscles, is attached to the membrane of the obturator
foramen, and posteriorly sends out a thin lamina that covers the
sacral plexus and pyriformis muscle. From the "white line "
the fascia extends downward and inward and is known as the
recto-vesical fascia." This recto-vesical process covers a cor-
responding surface of the levator ani muscle, becoming firmly
attached to the vagina and the rectum, and giving off from its
under surface fibrous sheaths which surround and follow these
tubes downward. (Quain, Heath.) To the bladder processes are
given off, which extend from the back of the pubis to the neck
of the organ, forming the anterior ligaments; and fascial bands
which are attached to the posterior lateral border of the vesical
base, forming the lateral vesical ligaments.
(C
If the student will now turn to Fig. 8 he will see, diagram-
matically, every detail of the construction of the pelvic floor. In
studying this diagram he should bear in mind that the female
floor is pierced by the vagina and the rectum, which tends to
weaken it. He should remember, however, that the vagina
is a mere mucous slit in the pelvic floor, whose walls are in appo-
sition. In the upright posture it makes an angle of about 60°
with the horizon, which is nearly parallel to the pelvic brim.
Pis the section of the body of the pubic bone; c is the pubo-

42
6
5
7
A TEXT-BOOK OF GYNECOLOGY.
FIG. 8.
444
P
24 3
PERPENDICULAR SECTION, FROM BELOW UPWARD, TO THE LEFT OF THE PUBIC
SYMPHYSIS, DIVIDING THE LABIUM THROUGH THE MIDDLE OF THE PUDEN-
DAL SAC. Vide text. (Savage.)
3.
2-
A
FIG. 9.
ક
5
P
THE RELATIONS OF THE MUSCULAR FLOOR OF THE PELVIS TO THE PRESEN-
TATION AT THE LAST STAGE OF PARTURITION.
1. Upper margin of the vaginal ring; 2. Infra-vaginal portion of triangular ligament
and transversus perinei muscle; 3. Their attachments to the tuberosity of the
ischium; 4. Lower part of levator-ani muscle; P. Perineal body; A. Anus.
THE ANATOMY OF THE FEMALE PELVIC ORGANS.
43
ischiatic line (white line, Fig. 7) between the pelvic fascia and
obturator fascia, to which the levator ani is attached laterally; d
is the recto-vesical fascia covering the levator ani muscle; p is the
posterior layer of the triangular ligament (perineal septum); m,
anterior layer of triangular ligament; s, under layer of superficial
perineal fascia; o, ischio-rectal extension of r, mass of fatty tissue
filling pudendal sac, and receiving the termination of the round
ligament, and fatty layer of superficial perineal fascia.
1. Sheath of deep layer of superficial fascia surrounding the
crus clitoridis and its erector muscle; 2. Transverse perineal
muscle; 3. Bulb of vagina; 4. Lower muscular fibers of perineal
septum extending between and m; 5. Gluteus maximus mus-
cle; 6. Ischio-sciatic ligaments; 7. Pyriformis muscle.
The relation of the muscular floor of the pelvis to the pre-
sentation at the last stage of parturition is well shown in Fig. 9.
It will be seen from this illustration how it is possible to have
those structures of the pelvic floor which afford its main support-
the diaphragmatic muscles, their fascia, and the triangular liga-
ment-relaxed and separated without any external injury to the
perineal body. Unless the student fully comprehends this fact
he cannot intelligently repair injuries of the pelvic floor.
THE RELATIONS OF THE FEMALE PELVIC ORGANS WITH THE
PELVIS AND WITH ONE Another.
Fig. 10 represents a median perpendicular section of the pelvis
from front to back, and shows both pelvic spaces. For the
purpose of illustration, the urethra, bladder, vagina, and rectum
are represented with their walls separated. This is erroneous,
for when empty the walls of all of these organs lie in apposition.
PERITONEUM.
The Pelvic Peritoneum Traced from Before Backward.-
At a point a little above the symphysis pubis the peritoneum of
the anterior abdominal wall is reflected to the bladder (Fig. 12).
From the fundus it dips down between the bladder and the
uterus to a point corresponding to the internal os; thence
over the anterior surface of the uterus. It forms between the

44
R
B
P
A TEXT-BOOK OF GYNECOLOGY.
FIG. 10.
V
14
C
m
L
1
MEDIAN PERPENDICULAR SECTION OF PELVIS. (Cazeaux.)
S. Section of pubic symphysis; B. Bladder, moderately distended; in front its outer
longitudinal coat passes off to the inferior edge of the pubic symphysis and to
the ligamentous process of the levator ani muscle, where it is attached; it bridges
over the urethro-pubic venous plexus, separating that space from the vesico-pubic
space above, which in turn is bridged over by the vesical ligaments formed by
the urachus and two remnants of the hypogastric arteries. The internal circu-
lar muscular coat of the bladder is well shown. The internal mucous folds loosely
adhere to the lining membrane and cover the lattice-like projections of the
inner circular coat into the vesical cavity. The entrance of the left ureter is
indicated by a black point. u. Urethra. The inner longitudinal muscular coat
is surrounded by m, m, outer circular coat. The muscular layers at u consti-
tute a true compound sphincter, composed of organic and voluntary muscular
fibers. C. Section of clitoris; L. Left labium; I. Left nympha; V. Vagina.
Its muscular coats blend with the tissues of the uterine neck. The long axis of
the uterine cavity is nearly at right angles with that of the vagina. P. Perineal
body. The many small vessels are indicated by black dots. The anterior sec-
tions of the lower muscular fibers of the rectum (internal sphincter) are immedi-
ately behind it. A. Anus, showing the columns of Morgagni; R. Rectum, show-

THE ANATOMY OF THE FEMALE PELVIC ORGANS.
45
bladder and the uterus the vesico-uterine pouch and the vesico-
uterine ligament.
From the anterior surface of the uterus it passes over the
FIG. 11.
U
A.II..
VUO
R
P
C
A VC. Ur
HORIZONTAL SECTION OF THE ABDOMEN, SHOWING THE PELVIC ORGANS FROM
ABOVE AND THE PELVIC CAVITIES.
V. Fundus of bladder moderately distended; U. Uterine body; A. H. Hypogastric
artery; D. Cul-de sac of Douglas; A. Aorta; V. C. Vena cava; Ur. Ureter;
P. Psoas muscle; R. Rectum. (Auvard.)
fundus, covering completely the posterior surface and descending
for about one inch (variable) on to the posterior vaginal wall.
ing the valves of Houston projecting into its cavity. All of the coats of the
rectum are included in these folds; they disappear entirely upon slight distention.
The internal sphincter (inferior circular fibers) are indicated by minute circular
markings; the posterior half of the external sphincter is indicated by lines near
the coccyx.
U. Left half of uterus retrodisplaced. Its central and more
vascular portion is indicated by black dots around which are its internal and
external muscular coats. P P. Vesico-uterine and recto-uterine (Douglas's
pouch) peritoneal folds.

46
A TEXT-BOOK OF GYNECOLOGY.
From this point it is reflected over the anterior surface of the
rectum, forming the pouch of Douglas. (Figs. 10 and 11.)
The Pelvic Peritoneum at the Sides of the Uterus.-
The two layers of peritoneum covering the anterior and posterior
FIG. 12.
d
a
FROZEN SECTION, SHOWING PERITONEUM, WHICH IS INDICATED BY DOTTED LINES.
a. Anus; b. Vagina; c. Bladder; d. Uterus; e. Below Douglas's pouch; f. Sym-
physis pubis. (Furst.)
surfaces of the uterus lie nearly in apposition at the sides of the
uterus, from which point they extend on either side outward and
somewhat backward to the sacro-iliac synchondrosis; at this
point they pass to the side walls of the pelvis. These two layers
of peritoneum form the broad ligaments.
THE ANATOMY OF THE FEMALE PELVIC ORGANS.
47
The Broad Ligaments enclose between their two laminæ of
peritoneum, lymphatics, blood-vessels, connective tissue, and
unstriped muscle. The Fallopian tubes are placed just within
their upper face margin. At the outer margin of the ligament
there is a portion (one inch) not occupied by the Fallopian tube,
which is the infundibulo-pelvic ligament of the ovary. The
ovary projects through the posterior lamina of the broad liga-
ment; enclosed in the two laminæ, between the ovary and
ampulla, is the Parovarium.
At the uterine end of the broad ligament, near its upper
angle, there is a longitudinal fold of peritoneum into which the
unstriped muscular fibers of the uterus are prolonged. It extends
from the upper angle of the uterus to the inner end of the ovary
(one and one-fifth inches) and constitutes the Ovarian Ligament.
The Pelvic Peritoneum Reflected from the Sides of the
Pelvis. At the sides of the pelvis the peritoneum descends and
is reflected on to the lateral surfaces of all of the pelvic organs.
At the lower lateral part of the body of the uterus it forms two
folds which extend outward and backward toward the second
sacral vertebra. These folds contain connective tissue and
unstriped muscular fiber, and constitute the Utero-sacral liga-
ments. (Fig. 11.)
Practical Points Concerning the Pelvic Peritoneum.-I.
There is no break in the continuity of the peritoneum, although
described in sections.
2. In operations involving the posterior vaginal fornix it is
an easy matter to open into the peritoneum. There is no opera-
tion involving the anterior fornix which endangers the peri-
toneum.
3. When the bladder is distended, and during parturition, the
organ can be penetrated above the pubis without injuring the
peritoneum.
THE ROUND LIGAMENTS OF THE UTERUS.
The Round Ligaments are the only uterine ligaments not
described in tracing the peritoneum. They vary in length from
four to five inches. Within the pelvis they are attached immedi-

48
A TEXT-BOOK OF GYNECOLOGY.
ately below and in front of the Fallopian tubes. A portion of each
ligament is included in the anterior fold of the broad ligament,
from which it passes, enveloped in a fold of peritoneum, to the
internal inguinal ring, having the same relations as the sperma-
tic cord in the male. After emerging from the external ring it
FIG. 13.
U
N
E
1
T
5
P
4
PUBIC TERMINATION OF ROUND LIGAMENTS. (Savage.)
U. Fundus uteri; P. Pubis where covered by pubic portion of aponeurosis of int. obliq.
muscle; L. Uterine extremity of round ligament; E. Aponeurosis of ex. obliq.
muscle; i. Internal oblique muscle; 7. Rectus muscle; N. Genital branch of
genito-crural nerve; 1. External terminating fibers of round ligament into outer
pillar of internal ring near Gimbernat's ligament; 2. Internal terminating fibers
into conjoined tendons of int. obliq. muscle and transversalis muscle near pubis;
3. Middle terminating fibers into upper part of external ring; 4. Internal pillars
of external ring; 5. Vessels of round ligament, nervous filaments, and middle
terminal fibers of round ligament descending into pudendal sac.
passes very close to the outer side of the pubic spine, into the
fibrous tissue of the mons and the upper portion of the labium
majus. Before passing into these structures it is broken up
into
several fine strands. (Fig. 13.) A number of operations upon
the round ligaments have recently been devised for overcoming
uterine displacements.

THE ANATOMY OF THE FEMALE PELVIC ORGANS.
49
THE PERITONEAL PELVIC POUCHES.
The Vesico-uterine Pouch lies between the bladder and the
uterus and contains no small intestine. (Fig. 14.)
The Paravesical Pouches lie one on each side of the bladder
in front of the broad and infundibulo-pelvic ligaments. They
probably contain intestine when the fundus is diverted to the
front, and certainly do when it is displaced posteriorly. The
Fallopian tubes also lie in these pouches.
PERITONEUM
HADAD LIGH
FIG. 14.
RECTUM
OUND LIG
UTERUS
TOAD LIG
UTERO-VESICAL LIOS
BLADDER
PERITONEUM
THE POUCHES AND REFLECTIONS OF THE PELVIC PERITONEUM. (Hodge.)
The Lateral Pouches of Douglas are bounded in front by
the broad ligaments; laterally by the pelvic walls; and poste-
riorly by the utero-sacral ligaments.
The Pouch of Douglas or Posterior Cul-de-sac is bounded
anteriorly by the uppermost inch of the posterior vaginal wall
and posterior aspect of the supra-vaginal portion of the cervix;
superiorly and laterally by the utero-sacral ligament; and pos-
teriorly by the sacrum and rectum with their peritoneal invest-
4
50
A TEXT-BOOK OF GYNECOLOGY.
ment. When the uterus lies in front it is partially filled with
intestine, which is crowded out when it is retroverted or retro-
flexed.
The depth of the pouch of Douglas varies. Normally it
descends for about one inch on to the posterior aspect of the pos-
terior vaginal wall. It is greater on the left side than on the
right. Pirogoff has made a section in which the peritoneum
dips down on the posterior vaginal wall till within about an inch
from the vaginal orifice. This occasional anomaly should be
borne in mind by the operator.
CELLULAR OR CONNECTIVE TISSUE OF PELVIS.
This includes the fascia, which is described in connection with
the muscles of the pelvic floor; and the loose cellular or connec-
tive tissue throughout the pelvis.
The Cellular Tissue fills in the spaces between the bladder,
uterus and rectum above, and surrounds the vagina and rectum
below, spreading out between the layers of broad ligament. It
passes by continuity from the bladder and uterus upward into
the iliac fossa, along the surface of the psoas muscle posteriorly,
and between the peritoneum and transversalis fascia anteriorly.
It is very scant between the anterior and posterior surfaces of the
peritoneum, but at the sides of the cervix exists as distinct, loose
tissue. It is most abundant between the folds of broad liga-
ments.
The pelvic cellular tissue acts as a cushion in breaking the
force or jar which would be felt with every step. It steadies the
pelvic organs, and from its peculiar web or sponge-like forma-
tion permits the blood-vessels and nerves to pass through it to
their distribution. It admits also of much displacement of the
pelvic organs either upward or downward (as in pregnancy and
prolapsus) without injury to the structures which pass through
it. This tissue is of the highest importance pathologically,
because of its liability to inflammation.

THE ANATOMY OF THE FEMALE PELVIC ORGANS.
THE UTERUS AND ITS ANNEXA.
FIG. 15.
17
V-
T
R
51
UTERUS AND ANNEXA.
C. The uterine neck; L. L. Left broad ligament; L. L. Part of right broad ligament;
M. Right ovarian ligament; O'. Right ovary; P'. P. Fimbriated extremities of
Fallopian tubes; R'. R. Round ligaments; T'. T. Fallopian tubes; U. Anterior
surface of uterine body; V. V. Vagina.
THE UTERUS.
The Uterus is placed between the bladder and the rectum.
Its anterior surface is almost straight, and its posterior convex at
its upper part. It is divided into body and cervix.
On making a coronal section (Fig. 16) the uterine cavity is
best seen. The cavity of the body is a triangular slit with its
apex downward. It is lined with mucous membrane and con-
tains three openings-those of the Fallopian tubes and the os
internum.
The Cavity of the Cervical Canal is conical or spindle-
shaped, and has two openings into it-the os externum from
below, and the os internum from above.

52
A TEXT-BOOK OF GYNECOLOGY.
The average length of the unimpregnated uterus, from the os
externum to the exterior of the fundus, is three inches. The
average length of the uterine canal, from the os externum to the
interior of the fundus, is two and a half inches.
The Cervix is divided into a vaginal and a supra-vaginal por-
FIG. 16.
CORONAL SECTION OF UTERUS THROUGH FALLOPIAN TUBES. (Savage.)
a. Uterine cavity; b. Canal of the cervix and its peculiar folds of lining membrane;
d. Internal uterine coat; c. Os externum; e. Uterine aperture of Fallopian
tubes; f. Fallopian tubes; g. Broad ligament; V. Vagina.
tion. The vaginal portion lies within the vagina. Upon digital
examination the os externum is felt as a mere dimple in
virgins; in women who have borne children it is transverse
and fissured.
In structure the uterus is composed, from without inward, of
peritoneum, unstriped muscular fibers, and mucous membrane.

THE ANATOMY OF THE FEMALE PELVIC ORGANS.
53
THE FALLOPIAN TUBES.
The Fallopian Tubes (Fig. 17) run sinuously from the
upper angle of each side of the uterus, and are inclosed in the
upper free margin of the broad ligaments. They vary in length
from four to six inches, the right being usually the longer of the
two.
Each tube is composed of three parts-the isthmus, the
ampulla, and the pavilion.
J
FIG. 17.
a
VIEW FROM BEHIND OF THE LATERAL ANGLE OF THE UTERUS, WITH PART OF
THE LEFT BROAD LIGAMENT, OVARY AND PAROVARIUM. (Henle.)
a. Uterus; b. Isthmus of Fallopian tube; c. Ampulla; g. Has Parovarium to the
right, and fimbriated extremity of Fallopian tube and ovarian fimbria just below
it; e. Ovary; f. Ovarian ligament; 2. Infundibulo-pelvic ligament.
The Isthmus is the uterine end of the tube. It is narrow
and straight, and its lumen will barely admit a bristle.
The Ampulla is curved and thick, with a lumen sufficiently
large to admit an ordinary sized sound.
The Pavilion (fimbriated end) is expanded into a funnel-
shaped extremity.
In structure the Fallopian tube is composed, from without in-
ward, of peritoneum, longitudinal and circular unstriped muscu-
lar fibers, and mucous membrane lined with ciliated columnar
epithelium.
54
A TEXT-BOOK OF GYNECOLOGY.
THE OVARIES.
The Ovaries are two oval-shaped bodies which project through
the posterior layers of the broad ligaments, one on either side of
the uterus. They vary in weight from sixty to one hundred and
thirty grains, and in length from one to one and one-half inches.
The ovarian ligaments have been described with the peritoneum.
In structure the ovary is composed of peritoneum, connective
tissue, unstriped muscular fibers, blood-vessels, nerves and lym-
phatics. The peritoneum is of a dull luster and is covered with
an epithelium made up of columnar nucleated cells, which is
known as germ-epithelium.
The connective tissue consists of two layers-the cortical and
the medullary. The cortical lies beneath the peritoneum and the
medullary near the hilum. Throughout the connective tissue are
innumerable Graafian Follicles varying in size from in.
As they advance toward and bulge from the surface they become
much larger than this and in due time rupture.
The Graafian follicles consist of—
(a) A tunica fibrosa (Ovicapsule);
(6) A membrana propria ;
1
30
(c) A layer of nucleated columnar epithelial cells—(Membrana
Granulosa);
(d) Liquor folliculi.
The Membrana Granulosa projects into the liquor folliculi
at one point, which is known as the discus proligerus. The
discus proligerus contains the ovum, which has the following
structure:-
(a) Zona pellucida, or external envelope;
(6) Yelk protoplasm;
(c) Germinal vesicle (7
(d) Germinal spot (0
3
in. diameter);
in. diameter).
THE VAGINA.
The Vagina connects the external and internal organs of
generation, and extends from the hymen to the cervix uteri. It
is bounded anteriorly by the bladder and urethra, and posteriorly
THE ANATOMY OF THE FEMALE PELVIC ORGANS.
55
*
by the perineum, rectum and lower inch of the cul-de-sac of
Douglas.
The Anterior and Posterior Vaginal Walls are continuous
at their sides and lie in apposition, so that the vagina is a mere
slit in the pelvic floor. In the upright posture it is nearly par-
allel to the pelvic brim (Fig. 18).
The Anterior Vaginal Wall is
from 2 to 2½ inches long, forming
at its junction with the cervix the
anterior vaginal fornix. It is sepa-
rated from the posterior wall of the
bladder by loose connective tissue,
but it is closely incorporated with
the urethra.
The Posterior Vaginal Wall is
more than an inch longer than
the anterior, forming at its junction
with the cervix the posterior vaginal
fornix.
In Structure the vagina consists
of mucous membrane, and two
layers of unstriped muscular fibers
surrounded by loose connective
tissue, which contains its outer
venous plexus. The mucous mem-
brane is made up of unstriped
muscular fibers, elastic tissue, con-
nective tissue, and epithelium (squa-
mous and cylindrical).
C.......
FIG. 18.
し
​
ď
VAGINA IN VERTICAL SECTION.
(Hart.)
a. Perineum; b. Urethra; c. Vagina;
e. Anterior lip of cervix; f. Os
uteri. The axis is not normal at
its upper part, as the uterus was
drawn back.
The Bladder, Urethra and Rec-
tum are well shown in Fig. 10.
The relation of the ureters to the
uterus and bladder cannot, however, be shown in either a vertical
or horizontal section of the pelvic organs. Since vaginal hys-
terectomy has become a popular and frequent operation a knowl-
edge of the exact location of the ureters is very important (Fig.
19). In the upper part of the pelvis they lie nearly parallel
until they cross the iliac arteries. The left ureter lies behind

56
A TEXT-BOOK OF GYNECOLOGY.
the sigmoid flexure and the right behind the lower end of the
ileum. After crossing the iliac arteries they extend along the
lateral walls of the pelvis downward, backward, and outward,
nearly to the spine of the ischium. At this point they bend
forward and inward, behind the uterine vessels, and pass beneath
the base of the broad ligaments, entering the bladder from
one-half to three-quarters of an inch in front of and below the
cervix.
FIG. 19.
C
L
U
R
A
B
RELATIONS OF THE URETERS AT THE LEVEL OF THE OS INTERNUM, AS SEEN
FROM ABOVE. (Polk.)
U. Uterus; B. Bladder; R. Rectum; A, A. Uterine Arteries; C, C. Ureters; L.
L. Utero-sacral ligaments.
There are three openings into the bladder-the orifices of the
two ureters and the internal orifice of the urethra-dividing it
into neck, base, and body. The ureteric openings are separated
from each other by an inch or an inch and a half. All above
these openings and the centre of the symphysis is the body; all
below is the base; and that triangular portion bounded by them
and the internal urethral orifice is the trigone.
Practical Observation: In vaginal hysterectomy, and in all
operations involving the broad ligaments, there is but little
danger of injuring the ureters in securing the base of these
THE ANATOMY OF THE FEMALE PELVIC ORGANS.
57
ligaments, if the operator applies the ligature or clamp close to
the cervix.
THE BLOOD-VESSELS, LYMPHATICS AND NERVES
OF THE PELVIS.
Blood-Vessels.-(v. Plate I.) The entire blood supply of the
pelvic organs and perineum is derived from the ovarian, uterine,
vaginal, and internal pudic arteries. The ovarian is a branch of
the abdominal aorta; the last four are all branches of the
anterior division of the internal iliac. At the isthmus of the
cervix a special branch of the uterine joins with its fellow to
form the circular artery.
The venous supply is very abundant and consists of numerous
and freely communicating plexuses. These plexuses are located
as follows:-
The Vesical Plexus, external to the muscular coat of the bladder.
The Hemorrhoidal Plexus, below the mucous membrane of the lower part of the
rectum.
The Vaginal Plexuses-one outside of the muscular coat and one in the sub-
mucous tissue.
The Uterine Plexus, in the muscular structure of the uterus.
The Ovarian Plexus (pampiniform plexus), between the folds of the broad
ligament.
Vast Venous Plexuses lie between the layers of broad ligaments and beneath
the peritoneum.
Nerves. The pelvic organs are supplied with both spinal and sympathetic nerves
as follows:-
a. Spinal
1. Inferior hemorrhoidal branch of pudic and fourth and fifth sacral
and coccygeal nerves supply the levator and sphincter ani muscles.
2. The fourth and fifth sacral and coccygeal supply the coccygeal
muscles.
3. The pudic supplies muscles of the perineum and the clitoris.
b. Sympathetic.-Inferior hypogastric plexus gives off branches to the vagina,
uterus, Fallopian tubes, and ovaries.
The nerves terminate in the muscular layers of the uterus in the nuclei of unstriped
muscle (Frankenhäuser). Those supplying the mucous membrane end in ganglia
(Hart).
Lymphatics. The lymphatic system of the pelvic organs is
very extensive and very important. The vessels are arranged in
a network surrounding the various structures and organs, and
freely communicate with the inguinal and pelvic glands. For a
more extended description of the lymphatic system, the reader
is referred to the special works of Hart and Savage. (v. Fig.
173).
CHAPTER III.
CASE TAKING.
Systematic inquiry should precede a local examination of the
female pelvic organs. It is, however, unwise for the physician
to restrict the patient's narrative by confining her to one of the
many case-records now in existence. A voluntary history is of
more value than one obtained by a series of cross-questions.
The average patient's imagination is influenced by set questions.
She should be permitted first to relate her own story, and as
much of it as the physician deems important he should note.
This will afford him a superstructure upon which to base a more
systematic examination. A faultless clinical record has not yet
been published. For the last five years I have used Miner's,
and, although imperfect, it possesses the merit of preventing the
examiner from confining himself to one set of organs, for the
general schedule is very complete. The gynecological form, as
modified by me, is as follows:
Menstrual and Marriage
Data.
First Menstruated at-
Character of pains at this time
(a) before flow; (b) during
flow; (c) after flow-
(d) Became regular after—
(e) Duration of flow ; (ƒ) quan-
tity-
(g) Time of change to more
pain; or (½) less pain—
(i) Time of flow when most
pains-
(j) Character of pains-
(k) Quantity increased at this
time; or (7) diminished; (m)
flow lasting-
Present Menstrual condition,
(n) Interval; (0) duration of
flow; () quantity; (9) time
of most pains-
(r) Character of pains;
(s) Special remarks—
MARRIAGE DATA.
No. of children and ages-
No. of Miscarriages-
Last Miscarriage occurred-
Last Labor lasted-
Special incidents of this or any
other Labor-
Character of Recoveries-
PRESENT CONDITION.
(Menstruation and Leucorrhea
above.)
Development of Present
Known Causes—
Symptoms-
Nervous Derangements-
Leucorrhea since—
Its character, quality
and source-
58
CASE TAKING.
59
Irritability of Bladder-
Constipation-
Special pains, locality
Inflammation of-
and degree-
Os, size of-
Pains increased by-
PHYSICAL EXAMINA-
TION.
Vagina-Size and tenderness-
Prolapse of Walls-
Erosions of-
Douglas's pouch-
Vaginal vault-
Cervix Uteri-
Size and position-
Flexures-
Laceration of—
Uterus-Mobility-
Position-
Flexure
Enlargement-
Ovaries-
Tubes-
Broad ligaments-
Pelvis-
Density-
Secretion-
Ulceration of—
Abrasion-
Vaginal discharge-
(a) Character; (b) amount; (c)
persistence; (d) duration-
General-
Diagrammatic outlines of the pelvis, so arranged that special
lesions can be quickly indicated, add greatly to the value of a
gynecological record.
THE SIGNIFICANCE OF PAIN IN DIAGNOSIS.
One or all of three general symptoms usually induce the non-
pregnant female to submit to a local examination. These are
some unnatural discharge from the generative tract, disordered
menstruation and pain. Pain, as an expression of disease, may
mean much or little, and the importance of interpreting its
significance correctly is self-evident. For the convenience of
study, it may be classified as follows:-
As Regards Location.—1. Lumbar region; 2. ovarian region;
3. hypogastric region; 4. sacral and coccygeal region; 5.
vulvar region; 6. lower extremities; 7. general.
As Regards Function.-I. Menstruation; 2. defecation; 3.
micturition; 4. coition.
As Regards Posture.-I. Erect; 2. sitting; 3. reclining.
•
AS REGARDS LOCATION.
Lumbar Region.-Pain in the back is a symptom which is
perhaps oftener complained of in uterine disease than any other.
*
60
A TEXT-BOOK OF GYNECOLOGY.
It may be the only manifestation of such disorder and is, pro-
bably, purely reflex. That it is not due to pressure is evident
from the fact that it is found when the fundus is directed forward
as well as backward, and in various lesions of the pelvic organs
giving rise to no pressure. It nevertheless occurs oftener in retro-
displacements and particularly in retroflexion. Expulsive efforts
of the uterus will likewise excite lumbar pain, hence it is a symp
tom of the obstructive form of dysmenorrhea, and occurs when-
ever the uterus contracts upon any foreign body or substance.
Prolapse of the ovary and lesions of the cervix and endometrium,
may also cause a most persistent backache.
Lumbar pain is to be differentiated from-
1. Lumbago;
2. Disease of the vertebræ ;
3. Disease of the kidneys;
4. Abdominal aneurism.
In lumbago muscular effort is painful; the patient finds it diffi-
cult to stand erect, and even impossible to stoop forward. The
onset is often sudden and it is uninfluenced by either emotion
or menstruation.
The clinical history in disease of the vertebra is important;
that of traumatism or constitutional bias is rarely absent. There
is usually tenderness upon pressure over the affected part, and
other local evidences of deformity and disease.
When kidney disease is suspected the only safe guide is a care-
ful examination of the urine.
Abdominal aneurism is a disease of middle life and occurs.
more often in males. The physical signs of aneurism are rarely
wanting.
Finally, menstruation aggravates nearly, if not all, pelvic lesions,
but does not influence the other affections under consideration.
Ovarian Region.-Few authors agree with Hewett that pain
in the groin is, in ninety per cent. of all cases, due to anteflexion.
It is more probably due, in the vast majority of instances, to
irritation or inflammation of the ovary. In character it is sting-
ing or burning, sometimes aching, more or less persistent, and
usually confined to one side-oftener the left. It is particularly
CASE TAKING.
61
distressing a day or two previous to menstruation, during exer-
cise and after congress. Not infrequently it can be traced to
sexual irregularities and is, therefore, often met with in prosti-
tutes. Sometimes it occurs at regular intervals between the
menstrual periods, the result, according to Priestly, of "inter-
menstrual" ovulation. Bermetz, DeMerie, and Noeggerath be-
lieve gonorrheal infection to be a prominent causative factor.
In certain instances uterine displacements and lesions will cause
reflex pain in the ovarian region, though oftener it is the result
of ovarian congestion and inflammation which follow in the
train of such lesions.
Hypogastric Region.-Pain in this region varies greatly in
character. It may be—
1. Bearing-down;
2. Intermittent;
3. Persistent;
4. Inflammatory;
5. Pain with symptoms of shock and collapse.
Bearing-down pain located in this region is suggestive of one
of several conditions, and, if persistent, calls for an exploration
of the pelvic organs. The most frequent cause is, undoubtedly,
the contraction of the uterus upon something within its cavity
or walls, when it is expulsive as well as bearing-down. Fibroid
tumors, polypi, retained menstrual blood, and a detached ovum
all excite the uterus to an unnatural contraction. Any disease
of the uterus involving change or shape of the organ may like-
wise cause a bearing-down pain. Such are the various forms of
displacement, particularly descensus with or without vaginal
prolapse; hypertrophic elongation of the cervix; and hyper-
plasia of the uterine body. Hematocele as a cause of bearing-
down pain will be considered under another head.
The most typical intermittent pain is that of normal labor. It
then comes and goes at regular intervals, with a decided period
of intermission. Pains simulating those of labor occur in abor-
tion and are not infrequently present in the non-pregnant. For
diagnostic purposes we may consider: (a) Pain resulting from
retained menstrual discharge; (b) pain due to the expulsion of
62
A TEXT-BOOK OF GYNECOLOGY.
•
an ovum or retained fetal membranes; (c) pain due to retention
of urine; and (d) pain due to tumors of the uterus.
In pain resulting from retained menstrual discharge, the history
will usually assist us in forming an intelligent conclusion. In
young girls the escape of blood externally may never have taken
place. If the menstrual discharge is retained, all of the symp-
toms of menstruation will recur at regular intervals, minus the
flow. The suffering is usually great, hysterical phenomena are
rarely absent, and, in due time, enlargement of the uterus may be
felt. A local examination will reveal an atresia, either of the
cervix or vagina, which is usually congenital. In women who
have menstruated the symptoms are similar, but the obstruction,
which may be temporary or permanent, is generally acquired.
If temporary, persistent contraction will overcome it; the uterus
will then be emptied and the pain will cease until the organ is
again distended. This type of obstruction is often the result of
flexion.
2
Intermittent pain due to the expulsion of an ovum or retained
fetal membranes has a history which, if elicited, will rarely mis-
lead a careful examiner. The patient will state that the menses
have been suppressed for one or more periods. With such a
history, and the discharge of blood suspiciously excessive, a
vaginal examination is imperative. The discharges should be
carefully examined for the products of conception, though it
must be remembered that in very early abortion these may be
entirely overlooked. Velpeau detected an ovum of about four-
teen days, which was not larger than an ordinary pea. It is
entirely possible for both conception and abortion to occur be-
tween two menstrual periods, when the diagnosis would be
exceeding difficult, if not impossible.
Retention of urine has caused intermittent pains, simulating
those of labor (Sedgwick). In the majority of instances such
retention follows labor, and is due to paralysis of the walls of
the bladder. In Dr. Sedgwick's case, however, it occurred in a
young woman supposed to be in labor.* She denied pregnancy,
but violent bearing-down pains, with short intervals, were pre-
* Hewitt, 4th Edition, Vol. II, p. 448.
CASE TAKING.
63
sent; the abdomen was enlarged to the size of a nine months'
pregnancy. Catheterization removed an incredible amount of
urine from the bladder, and the diagnosis became plain. I have
seen the bladder quite as much distended, but the patient was
moribund from puerperal septicemia.* Both of these cases
show most emphatically the danger of relying solely upon sub-
jective symptoms.
Intermittent pains resulting from tumors of the uterus are
usually of a bearing-down character, and have already been
described.
Persistent pain in the hypogastric region has its origin in cysti-
tis and is accompanied with more or less dysuria. The pain of
cystitis is subject to exacerbations and remissions, but is, never-
theless, persistent. The degree of suffering is influenced by the
extent and severity of the inflammation. Cystitis gives rise to
variable quantities of ropy pus in the urine.
Fibroma and Carcinoma Uteri and Flexions, may give rise to
persistent pain. The pain of cancer, when persistent, is peculiar,
although not pathognomonic. It does not occur until the peri-
uterine tissues are involved, when it is of a dull, aching, sickening
character, and may be burning or darting, seemingly transfixing
the whole pelvis (Rigby). Pains of this character, particularly
if associated with a suspicious discharge and cachexia, demand
of the examiner an immediate exploration of the parts. But it
should not be forgotten that cancer may progress even to ulcera-
tion through and into the bladder with little or no pain, and abso-
lutely no perceptible constitutional disturbance. Such a case
presented herself at my clinic during the winter of 1888. The
patient sought relief because of the discharge of urine through
an ulcerated opening into the bladder. An examination revealed
a broken-down scirrhus of the cervix, involving the base of the
bladder. There had been no pain, and the features were those
of a most vigorous woman.
The pain of inflammation as a subjective symptom is not
pathognomonic. It is acute in character, is usually traceable to
some definite cause, and constitutional symptoms are present;
* Transactions of the American Institute of Homeopathy, 1889, p. 676.
64
A TEXT-BOOK OF GYNECOLOGY.
the pulse is increased, the temperature elevated, and there is
more or less tenderness of the affected parts. Chilliness or a
decided chill usually ushers in such an attack. The severity of
the suffering varies according to the extent of tissue involved
and the constitutional impression made.
Pain with symptoms of shock, and collapse, is always of serious
import. It is suggestive of rupture or perforation of some one
of the pelvic viscera, with an escape of their contents or of blood
into the peritoneal cavity. Such an accident follows a ruptured
ectopic pregnancy cyst-according to Lawson Tait this is the
chief if not the only cause of hematocele-when the severity of
the shock depends upon the direction of the rupture: if between
the folds of the broad ligament, it is not necessarily very great;
if, on the contrary, it occurs in the free peritoneal cavity, there
is nothing to limit the quantity of blood discharged and the
symptoms at once become profound if death does not speedily
ensue. The ordinary symptoms of pregnancy may have pre-
ceded such an attack, but unfortunately the history often affords
no clue as to its nature. Hematocele due to causes other than
ectopic pregnancy is more apt to occur during or near a men-
strual period. In all forms of hematocele the presence of the
effused blood frequently excites much tenesmus and bearing
down.
Rupture of an ovarian cyst and of a gravid uterus give rise to
shock. The symptoms of a ruptured uterus do not differ from
those of a ruptured ectopic pregnancy cyst, except that the cause
is obvious, and if the accident happens during labor the child
will recede from the examining finger. The character of the
contents of an ovarian cyst will determine the symptoms after
rupture. If bland and unirritating the symptoms are not
marked; if purulent, fatal peritonitis may quickly follow unless
the abdomen is speedily opened.
The symptoms of shock, whatever the cause, are much the
same. It is characterized by prostration, fainting, feeble or
nearly imperceptible pulse, great paleness, pinched features, cold,
clammy perspiration, nausea and vomiting. Whenever the
foregoing symptoms present they demand of the physician
immediate and unremitting attention.
CASE TAKING.
65
Sacral and Coccygeal Region.—Pain in this region may be
due to actual disease of the bones or periosteum, to a displaced
uterus, to pressure exerted by inflammatory exudates, or it may
be purely reflex. A persistent pain in the sacral region always
gives rise to a suspicion of retro-displacement of the uterus.
Involvement of the retro-uterine cellular tissue will excite an
obstinate sacral pain. I have often found it present when the
utero-sacral ligaments were contracted by cellulitis. Mundé
observes that adenitis and angioleucitis-inflammation of the
lymphatic glands and vessels of the pelvic cellular tissue-are
many times the cause of sacral pain. When the coccyx is
implicated this bone should be carefully examined for the
evidences of injury or necrosis. Often the cause is entirely
obscure, and for the want of a better explanation the symptoms
are relegated to the domain of “neuralgia.”
Vulvar Region.-Pain in these parts usually has its origin in
some form of specific or non-specific inflammation in the region
of the labia or the introitus vaginæ. Disease of the Bartholinian
glands, abscess and specific or malignant ulceration may like-
wise excite vulvar pain. When vulvar pain is complained of
an inspection of the parts should be made before indagation is
practised.
Lower Extremities.-Pressure upon the sacral plexus of
nerves is the usual intra-pelvic cause of pain in the lower limbs.
Tumors, inflammatory deposits, and retro-displacements exert
such pressure, when the pain is confined to the posterior surface
of the limbs. Painful cramps in the calves of the legs, like those
occurring during labor, may result from pressure of any kind.
When the pain is confined to the anterior part of the thigh
another set of nerves is involved, and pressure is not the cause,
unless it is exerted by a psoas abscess, or by an anteflexed uterus.
Usually pain in this region is due to anteflexion; in other instances
the pain may be purely reflex. From whatever cause, it may
manifest itself in any portion of the limb to which the involved
nerve or nerves are distributed. I have seen a pain limited to
a very small portion of the anterior tibial region, which had
persisted for three years, disappear immediately upon repairing
a lacerated cervix. Irritable carunculæ, lesions of the rectum,
5
66
A TEXT-BOOK OF GYNECOLOGY.
bladder, and urethra, may give rise to pain in the lower extremi-
ties and even to paraplegia (Thomas).
General. The general symptoms of uterine disease are in-
numerable. In the chapters devoted to the Hystero-Neuroses
they are treated of in detail. It is sufficient at this time to
observe that any and every part of the body may be the seat of
disturbance whose origin is within the pelvis. This may be the
result of pain directly reflected, or secondary to depraved nutri-
tion, which follows in the train of disordered digestion and
malassimilation. The stomach, the liver, and the intestinal canal
are frequently affected in a reflex way, giving rise to dyspepsia,
cardialgia, nausea, vomiting, anorexia, jaundice, diarrhoea, con-
stipation, etc. Persistent pain in the occiput or vertex, worse
during menstruation, is almost pathognomonic of uterine disease.
So also is pain in the left infra-mammary region. Spinal irritation
is a part of the general "neurasthenia" which supervenes as the
nutrition suffers. In short, the entire system is often profoundly
and permanently impressed by utero-ovarian lesions.
AS REGARDS FUNCTION.
Menstruation.-Dysmenorrhea is the term by which painful
menstruation is designated. Few women are absolutely free
from pain during menstruation. By observing the character and
the circumstances under which it appears, it is possible to form
a very intelligent idea of the cause of the suffering. Pains radiat-
ing from the uterine region, occurring in paroxysms, and terminat-
ing with a more or less profuse discharge of blood from the
vagina, suggest an obstruction to the exit of blood. Pain in the
ovarian region for two or three days preceding the onset of the
flow, and usually relieved by it, would direct attention to the cor-
responding ovary as the probable seat of mischief. If the flow
is uninterrupted, the pain sharp and fixed, or comes and goes in
quick succession, and the patient is of a neuralgic or gouty dia-
thesis, the cause is probably systemic and there will be an absence
of local lesions. If it appears suddenly during menstruation, fol-
lowed by suppression and constitutional disturbance, acute con-
gestion or actual inflammation is the usual cause. Or if the
pains resemble those of labor and occur simultaneously with the
CASE TAKING.
67
flow, ceasing upon the expulsion of a clot whose nucleus is a
piece of membrane, the symptoms are probably due to mem-
branous dysmenorrhea.
Defecation.-From the standpoint of both physiology and
pathology the female pelvic organs are a unit, and the gynecolo-
gist can no longer ignore the influence which the rectum and the
bladder exert upon the generative organs. Painful defecation
may be the only symptom of which the patient complains. It
may be due to one or more of the following causes: Cancer,
stricture, fissure, hemorrhoids, polypi, prolapsus of the ovary,
pressure exerted by a sensitive fundus or cervix, pelvic exuda-
tion, fistula, rectocele, and proctitis. From the character of the
pain alone we can only surmise the nature of the lesion.
accurate diagnostic purposes a local examination is imperative.
Micturition.-Only the factors concerned in painful micturi-
tion are to be mentioned at this time. These are: Inflammatory
diseases of the bladder and urethra, malignant disease of the
bladder, vascular tumors and eversion of the mucous membrane
of the urethra, abnormal positions of the uterus, vesical calculi,
disease of the ostium vaginæ, and abnormal conditions of the
urine.
For
Inflammation of the bladder and urethra may be either acute
or chronic. If limited to the bladder pain is present more or less
constantly, and especially during micturition. The inflammation
in both instances may be due to a number of causes.
In the rare instances of idiopathic malignant disease of the
bladder the pain is worse immediately following micturition.
Turbidity of urine, with or without blood, is a symptom of carci-
noma of the bladder. In hematuria the source of the blood can
only be determined by a careful, and perhaps, repeated examina-
tion of the urine. The endoscope, in experienced hands, is very
useful in diagnosing vesical lesions.
Vascular tumors of the urethra, unlike urethritis, cause a per-
sistence of the pain during and after micturition which lasts for
an indefinite length of time. Eversion of the mucous membrane,
in both young girls and married women, may excite dysuria.
Benecke has reported three cases. of prolapse of the urethral
mucous membrane in young girls. I have seen, in an elderly
68
A TEXT-BOOK OF GYNECOLOGY.
woman, a similar prolapse as large as a pigeon's egg, which was
the cause of very painful micturition.
Abnormal positions of the uterus are more apt to cause
difficult than painful micturition. However, I have often seen
both difficult and painful micturition caused by retraction of
the utero-sacral ligaments, drawing the cervix and the base of
the bladder backward.
The pain resulting from vesical calculus is worse immediately
after the bladder is emptied, and is caused by the contact of the
bladder walls with the stone. Calculi almost invariably excite,
sooner or later, cystitis.
Any disease of the ostium vaginæ causing it to be inflamed
or ulcerated, will excite more or less pain after micturition.
Such are the various forms of inflammation, and specific and
malignant forms of ulceration. Excoriation of the vaginal out-
let is not infrequently due to abnormalities of the urine.
Coition.-Painful sexual intercourse, or dyspareunia, may be.
the one and only symptom for which the gynecologist is con-
sulted. The causes are many and may be enumerated as fol-
lows: Pelvic congestion from any cause; inflammation of any
of the generative or pelvic organs; ovarian tenderness or pro-
lapse; irritable caruncles; fissure or ulcers of the vulva, urethra,
or anus; neuromata of the vulva; coccygodynia; simple hyper-
esthesia without evident lesion; and atresia or stenosis of the
vulva or vagina.
AS REGARDS POSTURE.
Erect. The bearing-down pains, pains in the lower extremi-
ties, and those caused by inflammation, are aggravated by the
erect posture, and especially by walking. The distress incident
to relaxation of the pelvic floor with uterine and vaginal dis-
placements is often felt only in this posture.
Sitting. If the female perineum is pressed upon in the direc-
tion of the axis of the pelvic brim, there will be more or less
bulging of the hypogastrium. (Duncan.) Although the peri-
neum is protected by the tuberosities of the ischia, a certain
amount of pressure is exerted upon it in the sitting posture,
which pressure is communicated to the deeper parts. The bowels
and the pelvic organs are, therefore, in a measure squeezed
((
CASE TAKING.
69
while the woman is sitting, and, if inflamed or tender from any
cause, pain is liable to result. A prolapsed ovary may be im-
pinged upon in no other posture. Disease or displacement of
the coccyx and of the rectum may make sitting painful or im-
possible. When coccygodynia is present the pain is excruciat-
ing during defecation and while the patient is rising from the
chair.
Reclining. There are few if any gynecological diseases
made worse by the reclining posture. When the spinal cord is
secondarily involved, either in a reflex way or from nutritive
changes, Hammond gives a diagnostic point worth noting. It
is this: If the pain in the back be due to anemia of the cord it
is made better by lying upon the back, when the blood will
gravitate to the cord and its membranes, thus temporarily over-
coming the anemia; if, on the contrary, the pain be due to con-
gestion it will be aggravated in the dorsal posture.
The therapeutist will many times be able to base his pre-
scription upon the numerous and varied expressions of pain
which has its origin within the pelvis. To him it will be “sig-
nificant" both from a diagnostic and a therapeutic standpoint.
Nevertheless, the careful diagnostician and therapeutist will
weigh carefully the value of purely subjective testimony. Pain,
as a symptom, will prove most serviceable to him who holds path-
ology and drug pathogenesy to be inseparable.
CHAPTER IV.
THE SIGNIFICANCE OF DISCHARGES IN
DIAGNOSIS.
In a physiological state the mucous membrane of the genital
tract, extending from the ostium vagina to the fimbriated extre-
mity of the Fallopian tubes, secretes only enough fluid to lubri-
cate its opposed surfaces.
Over the inner surface of the labia, the clitoris and the nym-
phæ are sebaceous follicles which secrete sebaceous matter con-
taining butyric acid. The vulvo-vaginal glands, and numerous
muciparous follicles, are located at the sides of the vaginal aper-
ture, from which is poured a viscid mucus, which is increased
during the sexual orgasm. The secretion from the vaginal
mucous membrane is transparent and, under the microscope,
shows variable quantities of broken-down epithelium.
The arbor vite of the cervix contain many glands of the
racemose type, dilated at their extremities and extending deeply
into the connective tissue. (Ruge and Veit.) These are exceed-
ingly numerous and from them is poured a tenacious, viscid
secretion of an alkaline reaction. When in a state of activity
the quantity may be enormous. Microscopically, it contains
epithelium of the columnar variety and mucous corpuscles. The
cervical discharge rarely preserves its characteristic appearance
when it escapes from the vagina; after the secretion from the
cervix and the vagina commingle, the effect is a white, soapy or
creamy fluid.
PATHOLOGY.
No perfect division based upon the physical character of the
discharges can be made, for rarely is the discharge, as it escapes
from the vagina, derived from one source. The following classi-
fication is, therefore, made solely for the convenience of study.
70
THE SIGNIFICANCE OF DISCHARGES IN DIAGNOSIS.
71
I. Mucous;
2. Purulent;
3. Watery;
4. Sanious;
5. Offensive;
6. Hemorrhagic.
The character, source, and significance of these several dis-
charges are contrasted in the succeeding table.
DISCHARGES.
Character and Properties.
Mucous.-Contains oil
globules and epithelial débris.
If from the cervix, may
Source.
Cervical canal.
Uterine cavity.
resemble unboiled white of (Rare.)
egg. If from the vagina,
curdy looking and of acid
reaction.
Thick, creamy, and of
SIGNIFICANCE.
Exaggeration of normal secretion
after menstruation and during preg-
Fallopian tubes. nancy. Early stage of inflammation,
either specific or non-specific. Ane-
mia, chlorosis, Bright's disease, etc.
When plugging the cervical canal it
may be the cause of sterility.
External surface
acid reaction. Frequently and lips of cervix.
white or yellowish white and
at times almost membranous
in character. Epithelial cells
and oil globules are also
present.
Acid mucus. Occasionally Vagina.
Cervical metritis and endometritis.
Cystic degeneration.
parasites and fungi (Tricho-
monas vaginalis; Leptothrix
buccalis).
Purulent.-May be thick
Fallopian tubes.
or thin, profuse or scanty, (Rare.)
fetid or odorless, and some-
Uterine cavity.
times tinged with blood.
Same as above. May be Cervix.
sanious or, if gonorrheal,
thick and yellow.
Vagina.
Vulva.
Same as above. Quantity Suppurating cyst.
Pelvic abscess.
great.
Inflammation, either specific or
non-specific. Aphthous ulceration.
Pyosalpinx or chronic endome-
tritis, the result of either specific or
non-specific inflammation. If spe-
cific, gonococci may be present.
Suppuration of retained membranes
after abortion. Carcinoma. When
the quantity is considerable and non-
continuous, probably due to partial
cervical obstruction.
Carcinoma. Chronic inflammation
-specific or non-specific. Syphilitic
ulceration.
or
Opening either into uterus
vagina. History of tumor or pelvic
inflammation. Symptoms abate after
discharge of pus.
72
A TEXT-BOOK OF GYNECOLOGY.
CHARACTER AND PROPERTIES.
DISCHARGES.-Continued.
Source.
Watery.-Quantity vari- Uterus.
able, may be great. Hyda-
tidiform bodies often expelled
with fluid.
Dirty yellow or pale yel- Cervix.
low, clear, watery, or mixed
with blood. Quantity may
be very great.
Ovarian fluid.
Abdomen.
Urinous odor.
Bladder.
Sanious.-Leucorrhea
apt to be profuse.
Uterine cavity.
Discharges modified by Cervix.
character of lesion.
Blood-tinged pus. Quan- Pelvis.
tity usually great.
quantity. Frequently sanious.
Offensive. — Variable in
Uterine cavity.
Cervix.
Vagina.
Hemorrhagic.-Bright or
dark, thin, thick, or clotted.
Contains débris of uterine
tissue, fatty and oil particles
mucous corpuscles, or the
products of suppuration and
inflammation.
Variable; usually much
degenerated.
Vulva.
Uterine cavity.
General.
SIGNIFICANCE.
Pregnancy.-From the amnion.
Hydatidiform mole-rapid enlarge-
ment of uterus with absence of the
usual symptoms of pregnancy.
Tubercle.-Very rare; secondary
to general tuberculosis. Polypi (v.
Note 2). Cauliflower excrescence.
(Ramsbotham.)
Contents of ovarian cyst escaping
into Fallopian tube or uterus.——
History of abdominal tumor with
sudden diminution. (Rare.)
Vesico-vaginal or vesico-uterine
fistula. Frequently involuntary
while laughing or coughing.
Associated with menorrhagia, po-
lypi, and fibroma. Discharge al-
ternates with actual hemorrhage.
Fungoid or granular endometritis.
Abrasion or ulceration.
Hematocele.-Previous history of
shock, collapse, and inflammation.
Retained products of conception.—
History of pregnancy.
Sarcoma. Not offensive until
necrosis of tissue occurs; peculiar
discharge resembling washings of
fresh meat.
True carcinoma.-Not offensive
until necrosis of tissue occurs. (Char-
acteristic odor of malignancy.)
Retained menstrual blood.-Want
of cleanliness.
Excessive menstruation due to
uterine disease (endometritis, fibro-
ma, etc.). Displacement. Meno-
pause.-Age. Tumors.-Quantity
does not depend upon size. (Usu-
ally metrorrhagia and menorrhagia.)
Hematocele.-Shock and collapse.
Constitutional.-Purpura, tuber-
culosis, Bright's disease, syphilis,
plethora, malaria, exanthemata, dis-
orders of the heart, lungs, and liver.
((a) Centric.-Emotional.
(b) Reflex.—Ovarian,
vesical, rectal, and
mammary irritation.
NERVOUS.
THE SIGNIFICANCE OF DISCHARGES IN DIAGNOSIS.
73
CHARACTER AND PROPERTIES.
Hemorrhagic.-When due
to constitutional causes-ve-
nous.
When due to trauma-
tism-arterial.
DISCHARGES.-Continued.
Source.
Cervix.
Vagina.
Vulva.
Venous and arterial,
Rectum.
SIGNIFICANCE.
Constitutional.-Same as above.
Traumatism.-Surgical, accidental,
varicosis, thrombosis, vascular ex-
crescences.
Malignancy.-Pain, leucorrhea,
cachexia.
Congestion, polypi, fissure, malig-
nant and non-malignant ulceration,
traumatism, hemorrhoids.
DIAGNOSIS OF BODIES EXPELLED FROM THE VAGINA.
CHARACTER.
Early ovum.
Source.
Uterus.
Vesicular moles.-(Cystic Uterus.
degeneration of the chori-
onic villi.) Cysts simple.
True Hydatids.-Cysts
complex, i.e., closed sacs,
one within another.
Abdomen.
Uterus.
Membranous bodies. Dys- Uterus.
menorrheal membrane.
Vaginal Membrane.-En- Vagina.
tire mucous lining may be
cast off. (Rare.) Thin, trans-
lucent flakes.
Kidney.
Mucous membrane of Bladder.
bladder. Mucous membrane
of kidney pelvis.
SIGNIFICANCE AND DIAGNOSIS.
If any portion of the fetus be
found the diagnosis is conclusive.
Examine carefully for: (a) decidua
materna; (b) decidua reflexa; (c)
chorionic villi; (d) umbilical cord.
Always a product of conception.—
Early death of fetus, which dis-
solves and disappears; villi of chorion
becomes distended with fluid. Symp-
toms (v. "watery discharges" and
Fig. 20).
Not a product of conception.—
Microscope shows echinococci *
heads and booklets. (Very Rare.)
Not a product of conception.-
Rough and slightly flocculent exter-
nally, smooth internally. May be
cast off en masse or in pieces. No
evidence of chorionic villi. Repeti-
tion each month. Pathology obscure.
Inflammation and sloughing. Mi-
croscope reveals characteristic squa-
mous and cylindrical epithelium.
Cystitis and Pyelitis.-The shape
of the membranes, the history of
bladder or renal trouble and the
composition of the urine must be
studied.
* Vide London Obstet. Trans., vol. xii, p. 237.
74
A TEXT-BOOK OF GYNECOLOGY.
DIAGNOSIS OF BODIES EXPELLED FROM VAGINA.—Continued.
CHARACTER.
Source.
Fleshy Moles.-(Ovum Uterus.
with blood effused between
the membranes, which be-
comes organized.)
Placenta.-(May remain
for an indefinite time with-
out decomposition.)
Uterus.
Fibrous polypi. Fibroid Cervix.
tumors.
Cancerous masses.
Uterus.
Blood Polypi-Surface
may be dense, grayish, or
Uterus.
Vagina.
fibrinous looking. If from
the vagina, large.
Significance AND DIAGNOSIS.
Always a product of conception.—
Examine for chorionic villi. History
of pregnancy.
Expulsion usually preceded by
an offensive discharge. Early pla-
centa about the size of a pigeon's
egg. Examine for umbilical cord,
chorionic villi, etc. A positive diag.
nosis may be impossible.
Absence of all evidences of con-
ception. Microscope will reveal true
character. History of menorrhagia.
Fibroid tumors may become calci-
fied.
Occurs more often in connection
with abortion. Due to some obstruc-
tion either in the uterus or the vagina.
When recent, easily broken down.
Microscope will show blood-cor-
puscles.
The Microscope. This instrument is invaluable in the exam-
ination of suspicious discharges, curettings, adventitious growths,
etc. Its application is often the only reliable test in the early
stages of malignancy. Since the discovery of the gonococcus,
the microscope is relied upon more than ever as a means of
diagnosis. While the matter is yet sub judice the weight of
evidence tends to the belief that the presence of gonococci in
pus is pathognomonic of gonorrhea, though failure to find them
does not necessarily signify its non-gonorrheal origin. Bearing
upon this question the series of observations made by Aubert
are the most recent and valuable. The importance of this sub-
ject from a medico-legal standpoint is very great. Aubert's
method of examination is as follows :*—
A drop of pus is placed upon a glass slide, spread very thinly
with another slide, and allowed to dry. This is then stained with
* Lyon Médical, February, 1889.

THE SIGNIFICANCE OF DISCHARGES IN DIAGNOSIS.
75
an alcoholic solution of methyl violet diluted with water. Ex-
posing the specimen for a few seconds, it is then washed with
water, left a little moist, covered with a thin cover glass, and
placed under the microscope. The gonococci appear in stained,
FIG. 20.
VESICULAR OR HYDATIDIFORM MOLE. Museum R. C. S. (Photographed by
Author.)
scattered or grouped granules, either within or outside the pus
cells.*
*NOTE 1.-Aubert summarizes his conclusions as follows:-
1. A search for the gonococcus should always be made when an accurate diagnosis
is important, and when found should be considered characteristic of blennorrhagic
(gonorrheal) pus.
2. The microorganisms must be grouped in the protoplasm of the pus-cells and
76
A TEXT-BOOK OF GYNECOLOGY.
CONCLUSIONS.
1. An abnormal discharge or hemorrhage from the genital
tract is but a symptom of some abnormal condition, either
local or general. It is the first duty of the physician to deter-
mine the cause of this symptom.
2. When a continuous or exaggerated discharge of blood from
the uterus is not controlled by ordinary measures, a careful
examination, per vaginam, becomes imperative. Failing to dis-
cover the cause by this method, dilatation and exploration of the
uterus should always be made.
3. If any symptoms of malignancy of the fundus exist, the
uterus should be curetted and the products examined by an
experienced microscopist; or if the cervix is involved, and
proper treatment does not affect the induration, a section should
be exposed for microscopic examination.
around the nuclei in order to be characteristic. While a single well-defined cell may
be sufficient, full dependence cannot be placed upon cocci, scattered or in groups,
outside the pus-cells.
3. Dependence should not be placed upon a search for gonococci unless the pus is
obtained directly from the secreting surface and immediately spread out and dried.
The staining and examination can then be made at leisure.
4. It is impossible, at the present time, to determine positively as to the presence or
absence of gonococci from the examination of dried purulent discharge on linen,
because of the disintegration of the pus corpuscles, and the want of characteristic
grouping of the microbes.
5. Too much confidence should not, at present, be placed in the cultures made
from linen stained for some time with gonorrheal pus.
6. The numerous sources of accidental contagion should be remembered: there-
fore, while the presence of gonorrhea may be determined in a given case, its source,
particularly in little girls, should be made a matter of independent proof at the judicial
inquiry.
NOTE 2.—Case.—"Sarah W, October 27th, was admitted as an out-patient of
the Lying-in Hospital
Has had eleven children. Was confined with last child
one year ago. The labor was a favorable one, but there was some adhesion of the
placenta, which required the introduction of the hand for its removal. She has had
constantly some discharge ever since her confinement. Until the last month the dis-
charge has been chiefly of a watery character, and so abundant as to soak four or five
napkins each day, but scarcely to color them.
On making an examination
per vaginam, I found a tumor the size of a small hen's egg, insensible to the touch,
occupying the upper part of the vagina, the os uteri, and apparently attached to the
inner surface of the cervix uteri.”—“ Obstetrical Transactions,” Vol. I, p. 112.
* *
*
CHAPTER V.
PHYSICAL EXAMINATION.
INSTRUMENTS AND APPLIANCES NECESSARY FOR DIAG-
I. Table or chair.
NOSIS.
2. Specula: (a) Vaginal, (b) rectal, (c) urethral.
3. Dressing forceps.
4. Uterine sound and probe.
5. Uterine dilators.
6. Tenacula, volsella forceps, and depressor.
7. Curette.
8. Aspirator.
9. Stethoscope.
10. Tape measure and pelvimeters.
II. Thermometer.
12. Microscope.
13. Inhaler for anesthesia.
Table or Chair.-For ordinary office work I much prefer a
gynecological chair to a table. There are so many good chairs
on the market as to make it necessary for the purchaser to put
himself out in order to find a poor one. Personally, I prefer the
Harvard. It possesses nearly all of the requisite good points
and but few that are bad. The mechanism, while simple and
durable, is such as to permit of any desired position of the
patient. The gynecological positions are shown in Fig. 21 and
require no extended description. The Depew chair, manufac-
tured by R. Boericke & Co., likewise possesses especial merit.
Specula. Of the innumerable vaginal specula there are but
three general types now in use: (a) expanding, which are either
bi-, tri-, or quadri-valvular; (6) uni-valvular, or Sims's; and (c)
the cylindrical or tubular.
In America the bi- or tri-valve specula are in more general
77
78
A TEXT-BOOK OF GYNECOLOGY.
use by the non-specialist. The specialist, with an assistant at his
command, will ever prefer the Sims or some of its modifications.
The cylindrical is still very popular with many practitioners, par-
ticularly in England.
FIG. 21.


B-Dorsal position.
A-Full length reclining position.


Smit
C-For elevating the hips.
D-Sims position.
THE HARVARD CHAIR.
In selecting a bi- or tri-valve speculum both shape and
simplicity should be considered. The blades should not be too
FIG. 22.

G. TIEMANN-CC
THOMAS'S-CUSCO'S SPECULUM.
long, nor the circumference great enough to cause pain. I have
had in constant use for ten years a Cusco's of ordinary size (Fig.
22) and a Nott's Virgin (Fig. 23). Each possesses both merit
{
FIG. 23.

G.TIEMANN-CO
NOTT'S VIRGIN SPECULUM.
A
A
G TILMANN
FIG. 24.

BREWER'S SPECULUM.
FIG. 25.

BREWER'S SPECULUM USED AS A SIMS.
79
80
A TEXT-BOOK OF GYNECOLOGY.
and demerit, as do the Brewer (Fig. 24), the Graves and the
Goodell (Fig. 26). Both the Brewer and the Graves (Fig. 25)
can be converted into a uni-valvular speculum-a poor substi-
tute for the original Sims.
FIG. 26.

GOODELL'S SPECULUM.
Fig. 27 represents my own instrument. The advantages
claimed for it are the following:-
I. It is so constructed as to pass with ease into the posterior
vaginal fornix without causing pain at the ostium vaginæ, which
so often results from efforts to pass the tip of an ordinary bi-
C
a
FIG. 27.
GTIEMANN & CO.
valve instrument
when the uterus is
retroposed, par-
ticularly in virgins.
2. Its peculiar
shape makes it
perfectly self-re-
taining.

only
3. The
joints are at b, and
these can be un-
THE AUTHOR'S SPECULum.
locked in an in-
stant, making it
aseptic and convenient to carry. The blades are fixed by the
ratchet, c.
4. By means of the fixed handles the blades are under the
perfect control of the operator, and can be depressed or elevated
so as easily to expose the cervix. There being no set-screw, the
separation and closing of the blades requires but one hand.
There are many modifications of the Sims speculum, though
+
PHYSICAL EXAMINATION.
81
but few of these are an improvement upon the original design.
(Fig. 28.) The most important is the expansion, made by
Mundé, of one blade at its upper edge into a flange to prevent
the buttock from obscuring the view when no assistant can
FIG. 28.

G.TIEMANN
-CO.
SIMS'S SPECULUM.
be had. (Fig 29.) Porter's modification is highly spoken of
by those who have used it. The blades of the average Sims
speculum are too long and, particularly for operating purposes,
FIG. 29.

G.TIEMANN & CO.
MUNDE'S MODIFICATION OF SIMS'S SPECULUM.
too narrow. A virgin size makes an excellent rectal speculum
as well.
Many self-retaining univalvular specula have been invented,
the most useful being Emmet's (Fig. 30) and Cleveland's (Fig.
31), the object being to make an assistant unnecessary. They
6
82
A TEXT-BOOK OF GYNECOLOGY,
have never become popular and, probably, never will. With an
assistant there is no vaginal speculum equal to the Sims; with-
FIG. 30.
3. TIEMANN-Cu.
EMMET'S SELF-RETAINING
SIMS'S SPECULUM.
FIG. 31.

G TIEMANN & CO.
Cleveland's SPECULUM.
FIG. 32.

GTIEMANN FO
OTIEMANN COF
SIMON'S SPECULA.
out one some form of expanding instrument is infinitely more
convenient and useful for diagnostic purposes.
Simon's specula (Fig. 32) are uni-valvular, like the Sims, but
PHYSICAL EXAMINATION.
83
are used with the patient in the dorsal posture. The upper blade
has been made hollow, to which is attached a stop-cock so that
it can be connected with an irrigator (Frisch's modification).
Latterly I have been using Frisch's instrument for nearly all
operations within the vagina.
The cylindrical specula come in sets of five each (Fig. 33), and
are made of wood, metal, glass, gutta-percha, hard rubber, or
FIG. 33.

6 TIEMANN&CO
FERGUSON'S SPECULUM, TUBULAR.
horn. They vary in diameter from one-half to two inches, and
in length from four to six inches. One longer than five inches
is impracticable. I cannot conceive the usefulness of this instru-
ment as compared with a good bi-valve.
As already intimated, a small Sims's, or rather two Sims's,
specula make a very good rectal speculum, particularly after divul-
FIG. 34.

G.TIEMANN -CO
BI-VALVE RECTAL SPECULUM.
sion and when the patient is under anesthesia. For examination
at other times an expanding instrument is more useful. Very
good ones are shown in Figs. 34 and 35. Pratt's bi-valve is
also an admirable instrument, especially for operative purposes.
The use of urethral specula is necessarily more or less unsatis-
factory. Expanding instruments of any kind will expose the
outer third of the canal without any difficulty. One of the most
84
A TEXT-BOOK OF GYNECOLOGY.
popular specula constructed upon this principle is Skene's (Fig.
36), though the tips of dressing forceps, or, better still, an expand-
FIG. 35.

G.TIEMANN & CO.
WILLIAMS'S RECTAL SPECULUM.
ing ear speculum, will do very well. For examining the deeper
portion of the canal or the walls of the bladder an endoscope
FIG. 36.

G.TIEMANN&CO.
CATURN
SKENE'S URETHRAL SPECULUM.
or a cystoscope is necessary. Skene's endoscope (Fig. 37) and
the cystoscope of Nitze & Leiter (Fig. 38) are the best. To use
FIG. 37.
Fig 1

GTIEMANN
TIEMANI
a
Fig 2.
Fig 3
SKENE'S URETHRAL ENDOSCOPE.
either of these two instruments with success much practice is
required.
PHYSICAL EXAMINATION.
85
At least two Uterine Sounds-one stiff and one flexible—
should be in the possession of every physician who is called
upon to make gynecological examinations. Of the stiff sounds,
Simpson's is the most popular (Fig. 39). Although sufficiently
FIG. 38.

GTIEMANN & CO.
CYSTOSCOPE OF NITZE & LEITER.
stiff to retain its shape and curve despite any ordinary force, it
is flexible enough to be moulded by the finger. It is graduated
in quarter inches and inches, and at a distance of two and a half
inches from the tip there is a small knob indicating the normal
depth of the uterine cavity.
FIG. 39.

GEO TIEMANN&Co.
munu
SIMPSON'S UTERINE SOUnd.
Of the flexible sounds or probes, Sims's (Fig. 40) is typical.
Very flexible silver probes, bending at the slightest impediment,
are frequently required in penetrating the uterine cavity when
its canal is constricted or impinged upon by intra-uterine
FIG. 40.
G TIEMANN=CO
SIMS'S FLEXIBLE Probe.
growths. Elastic whalebone or hard rubber probes of similar
size are often necessary.
Tenacula are made in different shapes, the best for all pur-
poses being that represented in Fig. 41. The handle, for aseptic
86
A TEXT-BOOK OF GYNECOLOGY.
reasons, should be of metal. Volsella Forceps may be used
instead of the tenaculum for the purpose of fixing the cervix.
during examinations and operations.
FIG. 41.

G.TIEMANN &CO.
LONG ANGULAR TENACULUM.
Nott's Depressor (Fig. 42) is used to push the anterior
vaginal wall forward in using the Sims speculum.
FIG. 42.

6.TIEMANN.CO.
NOTT'S DEPRESSOR.
Hank's hard rubber Uterine Dilators are inexpensive and
good (Fig. 43). They come in sets of six each, thus giving
FIG. 43.

G.TIEMANN & CO
B
C
HANK'S HARD RUBBER UTERINE DILATORS.
twelve sizes. For rapid dilatation a steel instrument is necessary
(Fig. 44).
FIG. 44.

G.TIEMANN & CO.
WYLIE'S UTERINE DILATOR.
The Curette is used in diagnosis to remove tissue for micro-
scopical examination, therefore a sharp instrument (Simon's) is
PHYSICAL EXAMINATION.
87
ordinarily preferable (Fig. 45). When the sharp curette is
deemed unsafe, Thomas's dull wire instrument may be used
instead (Fig. 46).
A large Hypodermic Syringe with a long needle can be
advantageously utilized as an aspirator when only enough fluid
FIG. 45.

G. TIEMANN-CO.N.Y.
SIMON'S SPOON CURETTE.
is desired to ascertain its character. The most serviceable
aspirator for all purposes is Dieulafoy's.
Dressing Forceps are indispensable to the gynecologist. I
prefer a long, straight instrument made upon the principle of the
ordinary dissecting forceps. The late Professor Dunster devised
FIG. 46.


THOMAS'S DULL WIRE Curette.
such an instrument. Bozeman's dressing forceps is also a very
useful instrument and can be used as an applicator as well.
(Fig. 47.)
The Stethoscope is used in differentiating sounds within the
abdominal cavity.
The dimensions of the external surface of the abdomen and
88
A TEXT-BOOK OF GYNECOLOGY.
the size of the pelvis are determined by the Tape-Measure and
the Pelvimeters.
The use made of the Microscope in diagnosis is discussed in
Chapter IV.
A good Clinical Thermometer is a sine qua non in gyneco-
FIG. 47.

G.TIEMANN & CO.
BOZEMAN'S DRESSING FORCEPS.
logical work. Only by its use is it possible to determine actual
systemic disturbances, thus differentiating between pain due to
purely functional trouble and that resulting from pus or inflam-
mation.
Anesthesia.-An examination without anesthesia is rendered
unsatisfactory or impossible under the following circumstances:
FIG. 48.

FLAM ANA 2⠀
JUNKER'S INHaler.
(a) When the abdominal walls are unusually tense or tender;
(b) when phantom pregnancy is suspected; and (c) in young
girls when the parts are exceedingly tender. When used for
diagnostic purposes chloroform is the preferable anesthetic.
PHYSICAL EXAMINATION.
89
POSITIONS FOR EXAMINATION.
(a) level-dorsal,
I. Dorsal recumbent (b) gluteo-dorsal,
2. Lateral.
(c) lithotomy-dorsal.
3. Latero-abdominal, or Sims's.
4. Abdominal.
5. Genu-pectoral.
6. Erect.
It may be necessary in a given case to utilize more than one,
or, indeed, all of these positions. In America the dorsal posture
is usually the first resorted to for inspection and for digital or
ordinary specular examination. If the Sims speculum is used,
the patient is then placed in the latero-abdominal position. In
England the lateral or latero-abdominal is the usual one for both
digital and specular exploration. The patient's person should
be protected as much as possible with a sheet possessing an
opening a little below its middle, through which the abdomen
can be exposed and the hand or instruments passed. Gentleness
and tact are requisites without which no physician can become a
successful gynecologist.
1. Dorsal Recumbent.
(a) Level-Dorsal.-In this position the pelvic viscera are at
rest and the diaphragm exercises a minimum of displacing
power upon them. The knees are flexed so that the thighs are
almost at right angles with the abdomen; the head, shoulders,
sacrum, and soles of feet are on nearly the same plane.
digital and bimanual examination it is the best position.
In
(b) Gluteo-Dorsal.-The thighs are acutely flexed upon the
abdomen with the knees touching the thorax and separated as
widely as possible. This position is utilized when the vagina is
unusually long or when the perineum or abdominal walls are
exceedingly rigid. In it the symphysis is greatly elevated while
the sacral promontory is correspondingly depressed, so that it is
more easily reached with the finger. The vagina is directed
almost perpendicularly downward and, per rectum, the posterior

90
A TEXT-BOOK OF GYNECOLOGY.
surface of the uterus is accessible. Palpation is, in this position,
facilitated because of the complete relaxation of the abdominal
walls and the diminished intra-abdominal pressure.
(c) Lithotomy-Dorsal.-This position is much more com-
fortable for the patient than the gluteo-dorsal. The shoulder and
thorax are so elevated that the trunk rests upon an inclined plane
FIG. 49.
Krakhyourdel
LATERO-ABDOMINAL, OR SIMS'S POSTURE. (Skene.)
at an angle of about 20°, the feet remaining upon a horizontal
plane with the sacrum. Intra-abdominal pressure is increased
by the elevation of the thorax, hence this position is less adapted
than the gluteo-dorsal for bimanual examination.
2. Lateral.
The patient lies upon either side, preferably the left, her head
PHYSICAL EXAMINATION.
91
supported merely by a pillow. The shoulders and hips are
perpendicular to a horizontal plane, the hips down to the edge
of the table and the thighs flexed at right angles to the body.
The lateral and posterior portions of the pelvis are more accessible
to the examining finger than in the dorsal positions. Thus a
slight perimetric exudation, or a dislocated ovary which escaped
observation while on the back, may be detected. It is the
usual position for explorations of the rectum. However, nearly,
if not quite, as much information can be gained with the patient
either upon her back or in the latero-abdominal position.
3. Latero-abdominal, or Sims's.
While other forms of specula can be introduced in this posi-
tion, it is chiefly used for the introduction of the uni-valvular or
Sims's. In it the abdominal viscera gravitate forward and down-
ward away from the pelvic cavity. By admitting air into the
vagina and separating the labia the whole vaginal tract is
exposed. The correct position, together with the proper method
of holding the speculum, is beautifully shown in Fig. 49. The
patient lies upon her side, usually the left, her head supported by
a low pillow, and on a perfectly flat, hard table. The left arm is
thrown out behind and hangs over the edge of the table, while
the left shoulder, the lower half of the chest, and the left hip
touch the table. The thighs and knees are flexed at right
angles to the body, the right knee slightly overlapping the left.
A lateral or downward inclination of the table greatly facilitates
the examination. The position is unrivaled for ocular examina-
tion, and is imperative in many operative procedures on the
cervix and vagina.
4. Abdominal.
In this position the abdomen and thorax rest upon the
examining couch. To the gynecologist it is useful only when
it is deemed necessary to examine the spine, the posterior wall
of the pelvis, and the back.
5. Genu-pectoral.
As the name implies, the patient rests upon her knees and
chest. One side of the face is supported by a low pillow. Her
92
A TEXT-BOOK OF GYNECOLOGY.
thighs are at right angles to the pelvis, the knees somewhat
separated, and the feet slightly projecting over the edge of the
couch. In this position intra-abdominal pressure is practically
suspended. If the introitus is not too narrow the vagina fills
spontaneously with air and becomes ballooned. The uterus and
pelvic contents sink toward the abdominal cavity and the
fundus, unless crowded into the hollow of the sacrum or
attached, falls forward.
This position is useless for digital examination, because the
vagina becomes greatly elongated. When a retro-displaced
uterus cannot be restored in the ordinary way, it is invaluable.
Small incarcerated fibroids and ovarian tumors with long pedicles
can be more readily pushed out of the pelvic cavity in this
position. Pessaries and tampons are often advantageously intro-
duced before the patient turns upon her side.
6. Erect.
In the erect posture intra-abdominal pressure is increased to
its maximum, so that the pelvic contents sink lower than in any
other position. For esthetic reasons it is not resorted to when,
many times, valuable information might be obtained by so doing.
It is particularly desirable to make an examination while the
patient is erect after fitting a pessary. Excessive obliquities of
the pelvis and deformities of the spinal column are made more
conspicuous while the patient is standing.
CHAPTER VI.
PHYSICAL EXAMINATION.-(Continued.)
GENERAL CONSIDERATIONS:
In the schema given on the following page the senses of
touch, sight, and hearing are the only ones given for purposes
of physical examination. The sense of smell is also quite
important; from the odor of vaginal discharges we can at least
suspect malignant disease or the retained products of concep-
tion when they become decomposed.
I. IMMEDIATE Touch.
Palpation.
Position.-Palpation may be performed in any position, but
inasmuch as its gynecological use is usually restricted to palpa-
ting the abdomen, the level-dorsal and gluteo-dorsal are the most
satisfactory ones.
Method.-Both hands should be well warmed and laid gently
upon the abdomen, with the palmar surface down, and the whole
area manipulated between them. The pressure must at first be
light and then gradually increased; unless this point is observed
the contraction of the abdominal muscles will make the proce-.
dure useless. By engaging the patient in conversation muscular
tension can often be overcome. Deep inspiration with prolonged
expiration will likewise suspend voluntary resistance. (Mundé.)
Hegar and Kaltenbach recommend that the bladder and rectum
be filled with water and rapidly emptied for the purpose of pro-
ducing immediate relaxation. Anesthesia is often necessary.
So-called phantom tumors will disappear as if by magic when
the patient is anesthetized. The fingers should be spread out
and the whole abdominal surface uniformly palpated. By going
over region after region, it is possible to detect any abnormalities
which may be present. In the supra-umbilical region the finger
93
TOUCH.
METHODS OF PHYSICAL DIAGNOSIS.
SIGHT.
HEARING.
Intermediate.
Immediate.
Intermediate.
Produced sounds.
Existing sounds.
The sound.
(a) External inspection.
Percussion.
Auscultation.
(6) Mensuration.
(a) Uterine.
(c) Per speculum.
(b) Vesical.
(a) Aspirator.
(a) Sounds caused by pregnancy.
(b) Sounds caused by tumors.
(c) Crepitation.

(6) Microscope.
Immediate.
Palpation.
Simple touch.
Vaginal.
b) Rectal.
(c) Vesical.
Double touch.
Conjoined manipulation.
(a) Vagino-abdominal.
(6) Recto-abdominal.
(c) Recto-vesical.
The thermometer.
1. Vaginal.
2. Rectal.
3. Urethral
PHYSICAL EXAMINATION.
95
tips should be directed upward and backward; in the umbilical,
backward; and in the infra-umbilical, downward and backward
into the pelvic cavity. In normal conditions the sensation is
not unlike that of manipulating plastic fluid. Thickening of the
skin, circumscribed areas of resistance, nodules, tumors, fluid
collections, etc., should be looked for and mapped out.
Regions of Abdomen.-
For diagnostic purposes the
abdomen is divided into re-
gions, which are shown in
Fig. 50.
The following structures
are found in these régions :-
Right Hypochondriac.—Right
lobe of liver; gall bladder;
hepatic flexure of colon;
part of duodenum; part of
right kidney; suprarenal
capsule.
Epigastric.-Right half of
stomach; pancreas; liver.
Left Hypochondriac. - Spleen
and narrow extremity of
the pancreas; cardiac end
of stomach; the splenic
flexure of colon; upper part
of left kidney; left supra-
renal capsule; occasionally
a part of left lobe of liver.
Right Lumbar.-Part of the
duodenum and jejunum;
the ascending colon; lower
half of right kidney.
4
driac.
FIG. 50.

2
3
5 G
7
8
9
6
REGIONS OF ABDOMEN.-(Edis.)
I. Right hypochon- 4. Right lumbar.
5. Umbilical.
6. Left lumbar.
3. Left hypochon- 7. Right iliac.
driac.
8. Hypogastric.
9. Left iliac.
2. Epigastric.
Umbilical.-Part of the omentum and mesentery; lower part of
the duodenum, with some convolutions of the jejunum and
ileum; transverse part of colon.
Left Lumbar.-The descending colon; lower half of left kidney
with part of the jejunum.
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A TEXT-BOOK OF GYNECOLOGY.
Hypogastric.-The uterus when in the gravid state; convolutions
of the ileum; the bladder if distended.
Right Iliac.-The termination of the ileum; the cecum, with
the appendix vermiformis.
Left Iliac.—The sigmoid flexure of the colon.
Vaginal Touch.
Position.-Preferably the level-dorsal for routine examination.
English specialists prefer the lateral or latero-abdominal. It is
often advantageous to practise touch in several positions.
Method. The index finger of either hand may be used. It
should be scrupulously clean and the nail reasonably short.
Pure castile or antiseptic soap of some kind is the best lubricant.
The vaginal orifice is most easily reached by sweeping the finger
forward from the buttocks over the anus, perineum, and
fourchette. Avoid contact with the clitoris if possible. The
lax vaginal orifice in multiparæ makes it easy to find, and often
the introduction of two fingers is necessary. In passing the
finger or fingers into the vagina the examiner should note :-
1. Vulva.-If pain is caused by an attempt to introduce the
finger the parts should be inspected for-
(a) Inflammation, abrasions, or ulcerations;
(b) Labial abscess;
(c) Urethral caruncle;
(d) Eczema vulvæ.
Protrusions or tumors at the ostium vaginæ may be due
to-
(a) Cystocele or rectocele;
(b) Procidentia uteri, the cervix presenting;
(c) Inversio uteri, the fundus presenting;
(d) Uterine and vaginal neoplasms;
(e) Imperforate and bulging hymen.
2. Hymen.-Observe-
(a) Carunculæ myrtiformes. Their presence indicate
parturition at or near term ;
(b) Whether perforate or imperforate.
3. Vaginal Walls.-Observe the degree of moisture and heat,
PHYSICAL EXAMINATION.
97
the presence or absence of rugæ, fistulæ, foreign bodies,
length and diameter of canal.
Length. The walls are increased in length by-
(a) The ascent of the uterus into the abdominal cavity,
as in ovarian or fibroid tumors.
They are shortened by-
(a) Prolapsus uteri, with cystocele or rectocele ;
(b) Ante- or retro-uterine displacements;
(c) Inflammatory adhesions and cicatricial bands;
(d) Congenital atresia, partial or absolute.
Capacity. There is diminished capacity in-
(a) Any of the conditions affecting the length;
(b) Vaginismus ;
(c) Tumors within the pelvis or vaginal walls.
4. Cervix.-Position.-It is lower than normal in the vagina in-
(a) Prolapsus uteri;
(b) Hypertrophic elongation.
Direction. The direction may be nearly if not quite
normal in flexions of the uterus. It points in-
(a) Retroversion, directly forward;
(b) Anteversion, directly backward;
(c) Prolapsus, directly downward.
Length. The normal length is nearly one inch. It is
shortened physiologically in-
(a) Pregnancy (apparent) and immediately before and
during labor;
(b) Multiparæ;
(c) Advancing age.
It is shortened pathologically in-
(a) Super-involution;
(b) Non-development;
(c) Parametric exudations, obliterating vaginal forn-
ices.
It is increased in-
(a) Hyperplasia, or hypertrophic elongation;
(b) Prolapsus.
Consistence.—It is hard in—
(a) Senile atrophy;
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A TEXT-BOOK OF GYNECOLOGY.
(b) Fibroid and malignant degeneration;
(c) Inflammation.
It is soft in-
(a) Pregnancy;
(6) Early stage of subinvolution.
5. Os Uteri.-Shape and Size.-It may be-
(a) Circular and smooth, as in nulliparæ;
(b) Transverse and irregularly notched, as in parous
women.
In patency it varies in size from admitting a small probe
to half an inch, or even an inch, in diameter.
increased-
(a) During menstruation (slightly);
(b) In subinvolution;
(c) In lacerations with erosions and eversions;
It is
(d) In ulceration, either malignant or non-malignant;
(e) Shortly after labor and abortion;
(ƒ) During the protrusion of some body-polypus,
ovum, clot, inverted fundus, etc.
6. Vaginal Fornices.-Posterior Fornix.-After carefully examin-
ing the cervix and os the finger should be carried around
the cervix into the vaginal fornices. Normally, the poste-
rior fornix has a feeling like that of the inside of the angle
of the mouth (Hart and Barbour). When felt from below
it is concave. Pathologically, it is rendered convex by any
body or mass projecting through the pouch of Douglas.
Such are-
(a) Feces in the Rectum.-Fecal accumulations pit upon
pressure, and if there is any doubt as to their
character the bowel should be thoroughly
emptied.
(b) A Retroverted or Retroflexed Fundus Uteri.-Bimanual
examination will fail to find the uterus in front.
Unless pregnancy is suspected the sound may be
used.
(c) Acute or Chronic Inflammatory Deposits.—The history
is that of inflammation with more or less immo-
bility of the uterus.
PHYSICAL EXAMINATION.
99
(d) Hematocele.-The history is that of shock and col-
lapse, followed by the sudden formation of a
tumor and inflammation.
(e) A Prolapsed Ovary.-It may be adherent or non-
adherent. If the latter, it can be pushed upward
out of the pouch. The ovary is often beneath a
retro-displaced fundus. It will be recognized by
its size, shape, and, above all, its exquisite tender-
ness upon pressure.
(f) Small Fibroid Attached to Posterior Wall.-Absence
of any history of inflammation or shock. The
bimanual will show the fundus to be in front.
The sound will indicate increased thickness of
the posterior uterine wall.
(g) Ascitic Fluid.-All of the fornices are impinged
upon by a pressure which is non-resisting. Ab-
dominal percussion and palpation will detect free
fluid within the peritoneal cavity.
Anterior fornix.-Except feces, any or all of the bodies
or substances felt in the posterior fornix, may be felt
in the anterior. The fundus uteri is often felt in
front and is recognized by the sound and bimanually.
Blood and inflammatory exudates rarely gravitate
into the utero-vesical pouch unless the quantity is
great, because the pouch of Douglas is the most
dependent part of the pelvis. The normally located
uterine fundus can always be felt through the anterior
fornix by practising the bimanual.
Lateral fornices.-The most frequent pathological con-
dition felt through the lateral fornices is an effusion
of either blood or the exudates of inflammation.
Dilated Fallopian tubes are felt laterally, but rarely
without the bimanual.
In withdrawing the finger from the vagina after completing
vaginal touch, the state of the perineum and pelvic floor should
be noted. The perineal body may be partially or completely
destroyed by laceration; or, there may be relaxation of the
pelvic floor without any injury to the perineum. If so, a finger
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A TEXT-BOOK OF GYNECOLOGY.
placed in each lateral sulcus of the vagina, and separated, will
detect the divided ends of the deep muscles and fascia beneath
the mucous membrane. The character of the discharge on the
finger should also be noted when it is withdrawn.
Rectal Touch.
Indications. In all instances where there is pain upon defeca-
tion the rectum should be examined. When vaginal obstruc-
tions exist, particularly in young girls with the hymen intact, a
rectal examination may be the only one permissible. The retro-
uterine structures and posterior wall of the uterus can best be
explored through the rectum. I make it a rule to examine the
rectum of every patient who consults me for the first time.
Method.-The bowel should be thoroughly emptied by ene-
mata. Wash the hand which has been used in the vaginal
examination for fear of infection. Lubricate the examining
finger with soap; fill the space under the finger nail with the
same material by drawing the nail over a piece of hard soap.
This is done to keep fecal or other matter from being introduced
under the nail. The lateral position is the most convenient one.
As the finger passes the sphincter, observe―
(a) The resistance of the sphincter;
(b) The presence or absence of tumors, fissures, etc.;
(c) The presence or absence of strictures, malignant ulcer-
ation, etc.
After the finger has penetrated the rectum there will be
detected a thick conical body projecting into the anterior wall,
which is the cervix. The posterior wall of the uterus, the inter-
vening pouch of Douglas, the sacral excavation, and the posterior
rectal wall should all be touched. By exerting traction upon
the cervix, per vaginam, the parts are much more accessible.
The introduction of more than one finger is rarely necessary.
For a thorough examination anesthesia and dilatation are often
required.
Vesical Touch.
Indications.-Immediate vesical touch partakes of the nature
of an operation, and hence is not resorted to except in the most
urgent cases. Indeed, owing to the great danger of incontinence
PHYSICAL EXAMINATION.
ΙΟΙ
following digital exploration of the bladder, the practice has
fallen into pretty general disuse. It is safer and easier to enter
the bladder, when necessary, through the incised vesico-vaginal
wall. Intermediate vesical touch with the sound is, however,
frequently practised.
Double Touch.
Method.-In double touch the index finger is introduced into
the vagina and the thumb into the rectum; or, conversely, the
thumb into the vagina and the index finger into the rectum; or
the middle finger may be substituted for the thumb. It is useful
in examining the recto-vaginal pouch and wall, as the structures
coming between the fingers can thus be accurately appreciated.
Conjoined Manipulation.
In the schema three varieties of conjoined manipulation are
given. These are: (a) vagino-abdominal, (b) recto-abdominal, (c)
recto-vesical.
Vagino-Abdominal.-This is by all odds the most important.
The patient should be placed in the level-dorsal position with her
abdominal walls as much relaxed as possible. This is best
accomplished by drawing the knees up and slightly elevating
the head and shoulders.
The finger or fingers should not be removed from the vagina
after practising simple touch until the bimanual has been per-
formed. Simple touch is but the first step of a bimanual. The
position of the two hands is well represented in Fig. 51. With
the internal fingers the uterus and annexa, together with the
pubic segment and anterior vaginal wall, are lifted up toward
the brim. The whole abdominal area over the pelvic brim
should be palpated with the external hand, which is gently but
not spasmodically depressed.
The first object of the examiner should be to locate the fundus
uteri. Its normal position is about three inches above the
border of the symphysis. By lifting the uterus upward with the
internal fingers and pressing downward in the direction of the
pelvic brim with the external hand, it will be, if in front, within
the grasp of the two hands. If retro-displaced, the two hands

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A TEXT-BOOK OF GYNECOLOGY.
will approach each other with nothing intervening except the
abdominal and vaginal walls.
The normal virgin uterus is pear-shaped although com-
pressed antero-posteriorly. Its entire length is three inches,
of which nearly one inch is intra-vaginal. At the fundus it is
nearly two inches wide and about an inch thick. Through the
FIG. 51.
CONJOINED MANIPULATION.
abdominal and vaginal walls all intra-abdominal bodies seem
larger than they really are. Nevertheless, an experienced
examiner ought to detect even a slight increase in the size of the
uterus, although he may not be able to determine its cause.
Such enlargement may be the result of-
1. Pregnancy. The uterus has a regular, spherical outline, with
an apparent equality of all diameters. There is a peculiar
PHYSICAL EXAMINATION.
103
feel, even in early pregnancy, which must be felt to be ap-
preciated. The cervix is soft and velvety. Vaginal dis-
coloration is present. The uterus is freely mobile.
2. Subinvolution or Areolar Hyperplasia.-The uterus is more or
less tender. Menstruation is not interrupted and is usually
profuse. The cervix is not softened and is apt to be
gaping.
3. Small Fibroid Tumors.-There is no tenderness, and menstru-
ation is oftener profuse than otherwise. The uterine walls
are irregularly thickened.
In suspected pregnancy it is unwise to introduce the sound.
Let the student be cautious in giving a positive diagnosis in
early pregnancy. The best diagnosticians are liable to be mis-
taken, and time is the only safeguard. It must not be forgotten
that conception may occur when the organ is pathologically
enlarged.
The external hand should now be moved to one side and an
effort made to compress the organs situated in the lateral portions
of the pelvis. By rubbing the external fingers over the internal
ones it is entirely possible, unless great obstacles exist, to
outline the broad ligaments and the ovaries; when either are
enlarged it is quite easily done. If the tubes are distended they
are recognized as fluctuating, "sausage-like" masses on one or
both sides.
Successful bimanual examination requires skill and experience.
A tactus eruditus results only from long practice. When once
acquired it will bring to its possessor that which in no small
degree goes to make a successful gynecologist. It is much
more satisfactory with some women than with others. Tender-
ness, rigidity, and thickness of the abdominal walls are interfering
factors. The first two can be overcome by anesthesia: in deal-
ing with thick abdominal walls, all that can be done is to relax
them as much as possible by a favorable position.
Recto-Abdominal.-What has been said concerning the in-
formation derived from rectal touch will apply here. The
external hand presses the contents of the pelvis toward the
finger in the rectum, so that the posterior surface of the uterus.
and the contents of Douglas's pouch are more readily reached.
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A TEXT-BOOK OF GYNECOLOGY.
By this method, too, retro-uterine tumors may be easily
grasped from above; and a distended sigmoid flexure is more
clearly determined.
Recto-Vesical examination is described by some authors as
though it were perfectly easy and safe. Personal experience
teaches me that the urethra cannot be dilated so as to admit the
index finger with impunity. Then, too, the movements of the
finger within the bladder are so restricted as to make touch
unsatisfactory. Its greatest utility is in determining the absence
of the uterus; and even here very nearly, if not quite, as much
information can be gained with the sound in the bladder and the
finger in the rectum.
CHAPTER VII.
PHYSICAL EXAMINATION-(Continued).
II. INTERMEDIATE TOUCH.
UTERINE SOUND.
Indications.-Unless counter indications present, it is the
duty of the physician to employ every means at his command
which will afford him information concerning his patient. The
use of the uterine sound is, therefore, called for in those instances in
which previous oral and bimanual examinations have not furnished
satisfactory information, providing no counter indications exist.
The examiner who has mastered the art of making the bimanual,
will have occasion to resort to the sound less often than he who
has not.
Counter Indications.-I. It is not to be passed if there is any
possibility of pregnancy; if menstruation is delayed for a few
weeks, or even for a few days, the sound should not be
employed.
2. It is not to be passed in cases of acute pelvic inflammation,
and the greatest caution must be observed in cases of subacute
or chronic inflammation.
3. With certain limitations, it should not be passed during
ordinary menstruation.
4. It should not be passed in advanced malignant disease of
the cervix or body of the uterus.
Dangers.-Observing due precaution, Mundé, in fifteen
thousand cases in which he has used the sound, has not had to
contend with results more serious than slight shock and uterine
colic. Nevertheless, it must not be forgotten that some uteri,
even though apparently healthy, react upon the slightest provo-
cation, and thus serious trouble may follow. Besides inflamma-
tion, the student should guard against—
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A TEXT-BOOK OF GYNECOLOGY.
I. Perforation of the Fundus Uteri.-This is apt to occur when
the organ is softened by disease or during the process of involu-
tion after labor or abortion. The accident has happened repeat-
edly, but fortunately it has not been followed by bad results.
2. Hemorrhage.-When an unnatural hemorrhage from any
cause has existed, or is still present, there is danger of re-exciting
or increasing it by the use of the sound.
3. Abortion. The examiner should never rely absolutely upon
the patient's testimony, especially if there exist reasons for
deception. As a safeguard against passing the sound into a
pregnant uterus he should—
(a) Always ask when menstruation last occurred;
(6) Always examine the abdomen for signs of advanced
pregnancy;
(c) Always perform the bimanual previous to its introduc-
tion.
Even with these precautions, there are few men of extended
experience who have not, during their career, unwittingly
induced an abortion.
Method of Employment.-Place the patient in the level-
dorsal posture, well down to the end of the table. The cervix
and fundus are previously located by digital and bimanual
examination. The speculum may or may not be employed. By
relying solely upon the sense of touch the direction of the
uterine canal can be ascertained and any obstacles to the
advancement of the sound more readily overcome. On the
other hand, if the speculum is used, the vagina and cervical
canal can be freed from septic matter-an important considera-
tion; and by fixing the cervix with a tenaculum the operator
can see exactly what he is doing. I therefore prefer, with few
exceptions, to introduce the sound through the speculum.
When no Speculum is Used.-Pass the index finger of the
right hand, properly lubricated, into the vagina, and touch the
anterior lip of the cervix (Fig. 52). Grasp the sound in the left
hand and guide it, with its concave surface directed toward the
concavity of the sacrum, into the internal os. Then-
I. If the uterus is retro-displaced it is gently pushed onward
with the concavity still directed backward until the internal os

PHYSICAL EXAMINATION.
107
is reached. When the handle is elevated toward the symphysis
the point of the sound will pass into the uterine cavity.
2. If the uterus is in normal position or ante-displaced, the
concavity of the sound, after the point has passed into the cer-
vical canal, is turned forward, when the handle is depressed
toward the perineum.
When the Speculum is Used.-If the bi-valve is used place
the patient in the ordinary level-dorsal position; if the Sims,
in the semi-prone. Wipe the vagina and cervix thoroughly
with a 1: 2000 mercuric solution. Apply to the cervical canal
FIG. 52.
Method of Introducing the Uterine Sound. (Hart and Barbour.)
impure carbolic acid. Next gently fix the cervix with a tenacu-
lum and pass the sound as directed above. Probes should always
be introduced through the speculum. Previous to introduction
the sound should be given a curve corresponding to that of the
uterine canal, as ascertained by the bimanual. Absolutely no
force is to be used in its introduction. The tip of the handle is
lightly grasped by the thumb and the first two fingers of the
right hand, and the point, instead of being pushed, is rather
coaxed and insinuated onward.
In turning the sound, either within the cervix or the uterine
cavity, observe the following facts: If the handle is twisted on
its long axis the tip will be forced to sweep around the arc of a
semicircle, as shown in Fig. 53, and serious injury to the uterus
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A TEXT-BOOK OF GYNECOLOGY.
may result. If, on the contrary, the handle is made to traverse
the arc of a wide semicircle, the point remains fixed or nearly
so, and no injury will ensue (Fig. 54).
Information to be Gained by the Use of the Sound.
1. The caliber and permeability of the cervical canal.
Normally it should admit the sound without difficulty. The
caliber is diminished in-
(a) Infantile cervices;
(6) Acute flexions. (The stenosis is usually at the os
internum.)
(c) Mucous polypi blocking up the cervical canal.
FIG. 53.
FIG. 54.


Incorrect Method of Turning Uterine
Sound. (Hart and Barbour.)
Correct Method of Turning Uterine
Sound. (Hart and Barbour).
2. The length of the uterine cavity.
In determining the length of the canal keep the finger upon
that portion of the sound corresponding to the external os when
the instrument is withdrawn.
The size of the normal uterine cavity, from the os externum
to the fundus, is two and a half inches. It is increased in—
(a) Subinvolution ;
(6) Metritis and endometritis ;
(c) Tumors attached to the uterus, and polypi;
(d) Pregnancy;
(e) After labor or abortion.
PHYSICAL EXAMINATION.
109
It is diminished in-
(a) Infantile uteri :
(b) Super-involution;
(c) Senile atrophy.
3. The direction of the uterine axis.
Normally it is inclined forward. It is altered in—
(a) Retro-flexions and versions;
(b) Ante-flexions and veisions;
(c) Lateral displacements (usually the result of cellulitis);
(d) Various degrees of prolapse.
4. The mobility of the uterus.
In health it is freely movable and without pain. It is oftener
fixed as a result of inflammation, but fixation may be due to
many pathological conditions.
5. The connection existing between the uterus and certain tumors.
Such are
(a) Small tumors found in the anterior and posterior fornices
of the vagina. If the tumor is the fundus uteri
the sound will penetrate it, and, if not adhered, lift it
out of its unnatural position.
(6) Large tumors within the pelvic or abdominal cavities.
The sound will show whether or not such tumors are
intimately attached to the uterus.
6. The differential diagnosis between an inverted uterus and a
polypus projecting into the vagina.
The length of the cavity is increased in polypi; in inversion
it is nearly, if not quite, obliterated, so that the sound penetrates
the uterine cavity but a short distance. Bladder and rectal
exploration are sometimes necessary.
7. The condition of the endometrium.
It is roughened in inflammation and cancerous degeneration.
Hemorrhage often follows its introduction when these conditions
present.
VESICAL SOUND.
Indications. Its most frequent use is to explore the bladder
for calculi or suspected morbid growths. In amputations of the
cervix, or in vaginal hysterectomy, the sound should always be
passed to determine the relation of the bladder to the uterus.
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A TEXT-BOOK OF GYNECOLOGY.
With the sound in the bladder and the finger in the rectum the
presence or absence of the fundus uteri above the superior pelvic
strait can be determined.
III. IMMEDIATE SIGHT.
EXTERNAL INSPECTION.
Observe first the figure, the color of the face and lips and the
expression of the eyes. This will give some information as to
the temperament and general health. By examining the tongue
and gums existing disorders of the digestive organs and blood
can be detected.
For inspecting the abdomen place the patient upon her back
with the clothing perfectly loose. Note-
(a) The size and shape of the abdomen;
(b) The condition of the umbilicus, whether prominent, flush,
or retracted;
(c) The presence or absence of pigmentation;
(d) The presence or absence of lineæ albicantes. These
may result from distention of the skin due to any
cause, and may be absent in women who have borne
children;
(e) The contractions of the uterus;
(f) The movements of the fetus;
(g) Irregularities upon the surface.
In all cases when suspicions of pregnancy exist inspect the
breasts. Observe-
(a) Their size, whether plump or flabby;
(b) The areolæ and enlarged veins ;
(c) The nipples, whether full formed or retracted;
(d) The secretion. In doubtful cases a slight secretion is
of but little value for diagnostic purposes.
Previously to making a digital examination inspect the vulvar
region, particularly if the presence of specific disease is sur-
mised. Observe—
(a) The situation, whether normal or too far back;
(b) The color and size of the labia ;

PHYSICAL EXAMINATION.
III
(c) The condition of the perineum and the gaping of the
vulvar orifice;
(d) The size of the clitoris;
(e) The color of the introitus
vaginæ; it is increased in
pregnancy;
(f) The appearance of the meatus
urinarius-presence or ab-
sence of caruncles;
(g) The character of the dis-
charge; and
(h) Eczematous eruptions.
Digital Eversion of the Rectum for
Inspection.-Place the patient in the
dorsal or latero-abdominal position,
introduce one or two fingers into the
vagina and press the tips in the direc-
tion of the rectum. It is possible to
expose in this way the mucous mem-
brane of the edges of the sphincter
FIG. 55.
and a portion of the anterior rectal DIGITAL EVERSION OF RECTUM
wall. Fissures and other lesions in-
volving this region of the anus are
(Munde).
thus exposed without the aid of a speculum. (Fig. 55.)
PER SPECULUM.
Vaginal Specula.
Specular examination of the vagina is by no means necessary
in all cases. It should, however, be made when previous digital
examination reveals any condition the exact nature of which is
uncertain. Such are: Hyperplasia of the cervix with or without
lacerations; carcinoma; abrasions and ulcerations; granular
vaginitis, etc. It is usually wise to resort to the speculum when
the patient consults the physician for the first time, unless
counter indications prevent.
Counter Indications.-Atresia vaginæ; acute inflammation;
imperforate hymen; hyperesthesia. In malignant disease it
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A TEXT-BOOK OF GYNECOLOGY.
should be used as seldom as possible and then with much
care.
Bi- and Tri-valve Specula.-Place the patient in the level-
dorsal posture with the feet supported in stirrups. The instru-
ment can also be introduced in the lateral posture. Grasp the
speculum, well lubricated, in the right hand and press the
rounded point of the closed blades into the vulvar cleft which
has been separated by the left hand. The transverse diameter
of the blades should correspond to the antero-posterior diameter
of the vulvar cleft. When the latter is penetrated, turn the
speculum so that the handles will be directed downward and
gently push it into the vagina in the direction of the cervix.
The handles are now expanded in such a way as thoroughly to
expose the cervix, and fixed with the set screw or ratchet. It
may be necessary to fix the cervix with a tenaculum. By
greater expansion it is possible to expose the entire vaginal
vault.
The speculum should be gently withdrawn, care being
observed not to pinch the vaginal mucous membrane between
the blades.
Uni-valve or Sims's.-Much pains must be taken to secure
the proper latero-abdominal position. Unless this is done the
use of this speculum will be disappointing. It is necessary to
have intra-abdominal pressure almost, if not quite, suspended.
Method of Introduction.-Select a blade of proper size and
lubricate its convex surface. Grasp the end to be introduced in
the right hand and gently lift the upper labium with the left
hand. Introduce the point of the blade and the finger into the
vaginal orifice, keeping the point directed well backward into
the posterior fornix. With the left hand steady traction is now
made backward, and slightly upward so as to elevate the upper
buttock and admit more light. The proper method of holding
the speculum is shown in Fig. 49.
The table must be so placed as to permit light to enter the
vagina: i. e. the buttocks should correspond very nearly to the
center of a side window while the head of the table is drawn
about eighteen inches to the right.
When an assistant is present, she may lift the labium during
PHYSICAL EXAMINATION.
113
the introduction of the speculum. If the anterior vaginal wall
obscures the view of the cervix, it must be pushed out of the way
with the depressor. This will rarely be the case if the patient
is in the correct position and the speculum properly held.
The cervix can, if necessary, be drawn into position with
a tenaculum.
Tubular or Cylindrical.-In England, where this speculum
is most often used, the patient is placed in the lateral position,
with the buttocks close to the edge of the couch. It may, how-
ever, be introduced in any position.
The exact location of the cervix must be carefully noted by
previous indagation. Separate the labia with the forefinger and
thumb of the left hand. The speculum previously lubricated is
now grasped in the right hand and the tip introduced between
the labia. Keep it well pressed against the fourchette so as not
to pinch the tissues in front by crowding them against the
unyielding pubic bones. With the side of the speculum corres-
ponding to the tip in contact with the posterior vaginal wall,
push it onward in the direction of the vaginal axis until the
vaginal roof is reached. Upon depressing the distal end the
cervix will project into it. Very often a tenaculum is necessary.
The Sims speculum affords the most perfect and natural view
of the cervix, vault of the vagina, and anterior vaginal wall. By
it alone is it possible to appreciate correctly cervical lacerations
and eversions. Both the bi-valve and tubular specula act as
expanding instruments, and consequently the parts are put upon.
the stretch. The principle of the Sims is entirely different, and
there is no pressure exerted to congest or distort the tissues..
For operative purposes it is indispensable.
What to observe in using a speculum. Note-
(a) The color and condition of the vaginal mucous mem-
brane;
(b) The position of the vaginal walls;
(c) The character of the discharge from.the vagina and
cervix ;
(d) The condition of the cervix and cervical canal. Look
for congestion, inflammation, abrasion, ulceration,
induration, and laceration;
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(e) If there is laceration, hook a tenaculum in either lip,
separate them and then endeavor to roll the parts in.
In this way the extent of the laceration and the amount
of cicatricial deposit can be determined.
Rectal Specula.
Indications. A specular examination of the rectum is called
for in all instances when previous digital examination and ever-
sion have not afforded necessary and precise information. This
is usually the case when the disease is deep seated. Such are:
Strictures, fistulous openings of a pelvic abscess, recto-vaginal
fistulæ, proctitis, and internal hemorrhoids. Any or all of these
lesions are not infrequently associated with pelvic and uterine
disturbances.
Method.-If the bi-valve is used, place the patient in the
lateral posture. First insert the finger through the anus to over-
come the resistance of the sphincter. After the distal ends of
the blades are introduced push the instrument inward and back-
ward until the handles or hilt approach the anus. So place the
blades before introduction that, when opened, the diseased area
will be exposed. Never turn the speculum within the rectum; to
examine the walls obscured by the blades withdraw and reintro-
duce it. Care should be taken not to pinch the rectal mucous
membrane in withdrawing the instrument.
If
Anesthesia is rarely necessary for the above examination.
a more thorough one is desired, the patient should be anesthe-
tized and the sphincter dilated. This is done in the following
manner :-Pass the two thumbs completely into the rectum with
the four fingers of either hand resting upon either natis. Steadily
but forcibly separate the thumbs until the fibres are felt to tear,
or until they are arrested by the tuber ischii on each side. The
rectal mucosa can now be examined with perfect ease as the
canal is converted into a yawning cavity. The walls are best
separated by two Sims specula, or with a large expanding
instrument. As a therapeutic measure dilatation will again be
referred to in considering the treatment of constipation.
PHYSICAL EXAMINATION.
115
Urethral Specula.
Indications.-Disordered micturition, when causes outside of
the urethra are not discovered, calls for urethral inspection.
The urethral lesions are: Fissure, ulceration, caruncles, and
neoplasms. The only counter-indication is acute or recent in-
flammation of the urethra.
Method. The patient may be either upon her back or side.
A reflected light will afford the best view. First pass a sound
and locate any sensitive point; no pain should be caused by
passing a sound into a healthy urethra. Now introduce the
speculum or urethroscope so that the diseased area will be
exposed. Gentleness and skill are imperative in exploring the
deeper portions of the canal.
IV. PRODUCED SOUNDS.
PERCUSSION.
To practice percussion, the patient may be placed in any posi-
tion, depending upon the surface to be percussed. In gyneco-
logical examinations it is practiced over the abdomen oftener than
over any other region, hence the patient is usually placed upon her
back. The middle finger of the left hand is placed flat upon the
abdomen, at one time lightly at another firmly. With the tips
of the middle fingers of the right hand strike the second phalanx
distinctly. The sound elicited will indicate whether air or solid
material lies underneath the finger.
V. EXISTING SOUNDS.
AUSCULTATION.
Auscultation may be either immediate or intermediate. Its
chief usefulness in gynecology is in differentiating pregnancy
from other causes of abdominal enlargement. The sounds
caused by fibroids are due to the large arteries which they con-
tain. Crepitation results from peritoneal roughness and adhe-
sions.
Sometimes loose ascitic fluid within the abdomen can
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A TEXT-BOOK OF GYNECOLOGY.
be detected by a splashing sound induced by the patient suddenly
changing her position.
Mensuration, the use of the aspirator, and the clinical ther-
mometer do not require special consideration. The uses of the
microscope have been defined in Chapter IV.
CONCLUSION.
The schema of the Methods of Physical Diagnosis has been
so arranged simply for the convenience of study. A limited
number only, or all of the methods therein contained, may be
necessary in any given case. It is not intended that the student
shall proceed with his examination in the order given. The
usual sequence of methods is as follows :—
1. External inspection. It may not be wise to inspect the
external genital organs until after vaginal touch is practiced;
2. Digital examination of the vagina followed by the bimanual;
3. Inspection per vaginal speculum;
4. Introduction of the uterine sound;
5. Palpation, percussion, mensuration, and auscultation, if
deemed necessary;
6. Examination of the rectum and the urethra if deemed
necessary;
7. The use of the clinical thermometer, particularly during
exacerbations of pain;
8. The application of the aspirator and the microscope as final
tests.
CHAPTER VIII.
THE GENERAL PATHOLOGY OF GYNECO-
LOGICAL diseases.
PRELIMINARY CONSIDERATIONS.
Many points bearing upon the pathology of gynecological dis-
eases are as yet unsettled. Indeed, the greatest difference of
opinion prevails concerning the importance of local lesions as
disturbing factors. Cause and effect are constantly being mis-
taken the one for the other. As a result we have in uterine
pathology two distinct parties:-
I. Those of the first party relegate to the sexual system of
the female, when it becomes diseased, the power to affect the
whole organism in a morbid way. This influence, it is main-
tained, is exerted through the sympathetic and cerebro-spinal
nervous systems; and, accordingly, the only way in which the
symptoms resulting therefrom can be permanently relieved is
by curing the local lesion.
2. Those of the second party, on the other hand, attribute the
local trouble to systemic causes. They believe that the sexual
organs exert but little, if any, influence on the general organism;
and that by directing the treatment to the general and constitu-
tional symptoms the patient can be restored to health without
local interference of any sort.
Again, those of the first party are by no means unanimous as
to the importance and significance of certain local lesions. Thus
Bennett and his followers gave to inflammation and ulceration
an exaggerated importance: according to this school, sympa-
thetic phenomena rarely occur except when the uterus is inflamed
or ulcerated. Hewett and Hodge undertook to establish a
special uterine pathology, based upon displacements, consider-
ing inflammation and ulceration of little, if of any, importance
as primary factors. Cervical lacerations constitute the founda-
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A TEXT-BOOK OF GYNECOLOGY.
tion of a pathology promulgated by men who revel in minor
operative treatment. Disease of the uterine appendages is, by
not a few, considered the chief cause of the ills which afflict
woman-kind.
The foregoing theories are the natural result of looking upon
the female sexual organs as anatomical entities instead of but
part of a series which, in their totality, constitute the organism.
No restricted pathology has been, or will be, able to survive the
rapid strides of gynecology. The physician who to-day ignores
local lesions in the treatment of gynecological diseases is quite as
culpable as he who would treat an amenorrhoea due to phthisis
or chlorosis by stimulating the uterus. It may not always be
possible to determine the order, but symptoms occur in patho-
logical succession, and effects never precede their causes.
NERVOUS AND BLOOD SUPPLY OF THE PELVIC ORGANS.
Organs developed from a common primordial structure possess
nerve communications whereby impressions originating in one
may be transmitted to others of a like structural evolution.
(Oliver.) From the temporary organs named Wolffian bodies,
the reproductive and urinary organs are developed by a process
of gradual evolution. There is, therefore, a perpetuation of
direct nerve influence between the sexual and urinary organs.
Indeed, there is a nervous and vascular connection existing
between all of the pelvic organs. The same system of vessels
and nerves supply largely the genital organs from the ovaries to
the perineum, and are presided over by the same genito-spinal
center. Consequently, all are involved to a greater or less
degree in any physiological requirement which nature may
impose upon any one. They participate alike in ovulation, men-
struation, conception, pregnancy, parturition, and involution.
(Byford.) A pathological process involving one organ is also
likely to implicate others. So, too, the rectum and the bladder
are physiologically and pathologically affected by similar influ-
ences; or if primarily involved, may reflect any irritation origin-
ating in them to the genital organs.
Thus we see that derangement of any one organ within the
pelvis may involve all; or, acting through the genito-spinal
GENERAL PATHOLOGY OF GYNECOLOGICAL DISEASES.
119
center, may exert a powerful influence for evil upon the whole
organism. Any system of uterine pathology, therefore, which
ignores the unity of the pelvic organs, and of the entire organ-
ism, must necessarily be imperfect.
HOW DISTANT ORGANS ARE INVOLVED.
Assuming, then, that distant organs are frequently affected by
pelvic disease, it becomes the duty of the physician to study the
modus operandi by which such affections are induced. In my
opinion, hyperemia and hyperesthesia of the pelvic organs are
essential factors in producing reflex symptoms in distant parts.
That is to say, without hyperemia or hyperesthesia, no matter
what the local lesion may be, there are no reflex symptoms. In
proof of this statement I cite the fact that displacements, lacera-
tions, and tumors of the uterus may exist for years without
causing the least general disturbance, unless increased sensitive-
ness or increased vascularity ensue. Again, the reflex symptoms
starting from the pelvis are nearly all made worse by menstrua-
tion, at which time the hyperemia and hyperesthesia are increased.
It would not be correct, however, to infer from this that reflex
symptoms inevitably result from hyperemia and hyperesthesia of
the pelvic organs. On the contrary, every gynecologist meets
with many cases where both are present, and in which no reflex
phenomena whatever occur.
NATURE OF THE LOCAL LESION CAUSING REFLEX Symptoms.
Ovarian and uterine disease,-displacements, lacerations, in-
flammation, subinvolution, congestion, etc.,— furnish the starting
point of reflex symptoms oftener than other pelvic lesions.
(Hegar, Schroeder.) Those of the urinary tract, the rectum, the
coccyx, the perineum, and the anus are also frequently responsi-
ble for such symptoms; in the latter list are fissure, lacerations,
carunculæ, vaginismus, and coccygodynia. In these various
lesions both hyperemia and hypersensitiveness may present
themselves, either alone or combined.
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A TEXT-BOOK OF GYNECOLOGY.
FORMS OF HYPEREMIA.
Hyperemia rarely exists except as a result of some definite
cause, and in order to cure it the cause must necessarily be
removed. According to Byford, it occurs in three forms :-
(a) Active Hypertrophic Hyperemia, as in fungoid degeneration
of the uterine mucous membrane, in fibrous tumors, in preg-
nancy and in conditions of subinvolution.
(b) Passive, Venous or Congestive Hyperemia, as when the blood
is confined to the uterus by some obstruction to its return.
Obstruction giving rise to this form of hyperemia may result
from uterine displacements, from cervical lacerations, or from
peri-uterine effusions.
(c) Inflammatory Hyperemia, caused by inflammation.
THE SEQUELA OF HYPEREMIA.
Active Hypertrophic Hyperemia, if this theory be correct,
gives rise to hypertrophy of the organ involved, because of the
exaggerated local nutrition. It is seen physiologically in
pregnancy and pathologically in fibrous tumors, fungoid endo-
metritis, and subinvolution.
Passive and Inflammatory Hyperemia give rise to fibrino-
plastic effusion, which becomes organized. This contracts and
cuts off the capillary circulation of the parts involved. The
natural structure of the uterus is supplanted by the connective
tissue thus formed, with resulting condensation and induration.
This is hyperplasia. (Virchow). When it is once established,
congestion and inflammation may entirely subside while hyper-
esthesia remains. This is probably due to the fact that the
terminal nerve fibers are involved in the condensation of tissue,
reflex symptoms frequently resulting therefrom.
The reflex symptoms in cervical laceration may result (a),
primarily, from the involvement of terminal nerve fibers dis-
tributed to the cervix by the cicatricial deposit, and (b) secon-
darily, from the hyperemia and congestion caused by the lacera-
tion and deposition of cicatricial tissue.
The inflammatory form of hyperemia will account for those
circumscribed points of induration so often found in the cervix
GENERAL PATHOLOGY OF GYNECOLOGICAL DISEASES. 121
and in the walls of the fundus. They result from protracted
vascularity of the part or parts involved. (Byford).
Abrasion and ulceration of the cervix may follow in the train
of hyperemia and inflammation. Abrasion is a frequent sequela;
true ulceration from this cause alone is exceedingly rare. Both
abrasion and ulceration result from impaired nutrition of the
mucous membrane because of the hyperemia of the fibrous
structure of the cervix. So-called granular and cystic degenera-
tion of the cervix has for its basis hyperemia and inflammation.
(Cazeaux.)
THE NEUROSES.
We have seen that in the condition called hyperplasia, hyper-
emia may be absent. In these instances the pain is readily
accounted for by the unnatural deposit of hyperplastic tissue.
There are many cases, however, where the genital organs are
exquisitely sensitive and yet where the most careful examination
fails to reveal the evidences of disease. Congestion, inflamma-
tion, abrasion, displacement—all are absent, and yet there is pain
and sensitiveness in one or all of the pelvic organs, and reflex
symptoms are innumerable. The form of dysmenorrhea known
as "neuralgic" frequently occurs in connection with these
symptoms. The older authors called a uterus thus affected
“irritable.” The term is quite as comprehensive as is "neurosis."
Both describe a condition, without defining its cause, and both
are used to hide our ignorance. Patients rarely, if ever, die from
this disorder, and if it has a pathology it is so chameleon-like
in character that it has not yet been defined.
How GENERAL SYMPTOMS ARE INDUCED BY LOCAL DISEASE.
Disease of the genital organs gives rise to general symptoms
in one of two ways: (a) by reflex irritation; or, (b) by deprav-
ing nutrition. An irritation is conveyed to the genito-spinal
center, and thence reflected to all organs with which this center
communicates. In this way the stomach, bowels, liver and
nervous system become implicated. That the stomach is oftener
involved than any other organ, is shown by the nausea and
vomiting so often present in early pregnancy. If the cause,
other than pregnancy, persist, digestion is interfered with and,
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A TEXT-BOOK OF GYNECOLOGY.
sooner or later, the nutrition is compromised. The depraved
blood does not carry to the nerve centers that which they need
to sustain them and they become anemic. Exhaustion soon
supervenes and often becomes profound, giving rise to nervous
prostration or neurasthenia, a condition receiving detailed atten-
tion in the chapters devoted to the HYSTERO-NEUROSES and to
GENERAL TREATMENT.
HOW LOCAL DISEASE IS INDUCED BY SYSTEMIC DISTURBANCE.
Since nutrition may be affected from many causes, so-called
nervous prostration frequently occurs when the pelvic organs
are perfectly healthy. This condition is nearly always attended
with circulatory disturbances. We know that the vaso-motor
system presides over the circulation. It dilates and contracts
the caliber of the blood-vessels, and wear and repair depend
upon the proper adjustment of this function. If the equilibrium
of the ebb and flow is disturbed, local anemia or local hyper-
emia takes place. The cheeks are affected in this way when
they become pale as a result of fear, or when they become
reddened as a result of shame. This is physiological. The
flushes of heat so frequently present during the climacteric
period is another example which borders upon the pathological.
If this equilibrium of the circulation is destroyed from any
cause whatever, the internal organs are as often affected as is
the skin. Such a cause may be mal-nutrition, nervous shock,
or indeed anything that profoundly impresses the system. If
the brain is involved, either insomnia or drowsiness occur,
depending upon whether the brain is hyperemic or anemic.
Flatulence, gastralgia, and nervous dyspepsia result when the
stomach is similarly affected. The womb and the ovaries are
oftener implicated than any of the internal organs, and become
hyperemic or anemic as the case may be. If the former, con-
gestion with all its concomitant symptoms-menorrhagia, leu-
corrhea, tenderness, etc.,—occur without any local cause; if the
latter, amenorrhea or scant menstruation. (Engelmann.)
Hyperemia, congestion, and anemia of the uterus are likewise.
frequently caused by those general or, organic diseases of the
body which tend either to deprave the blood or to obstruct the
GENERAL PATHOLOGY OF GYNECOLOGICAL DISEASES. 123
pelvic circulation in a mechanical way. The disorders especially
tending to deprave the blood are enumerated in the succeeding
section. The diseases of the lungs, liver and heart may congest
the pelvic organs in a mechanical way. Menorrhagia, amenor-
rhea, and ovarian irritation, or any other pelvic lesion, may
therefore be due to general as well as to local causes.
TEMPERAMENT AND CONSTITUTIONAL BIAS.
In dealing with gynecological diseases, the temperament and
constitutional bias cannot be ignored. One patient will, without
suffering the least inconvenience, go through life with a pelvic
lesion which, in another, would give rise to the most distressing
symptoms. It is this fact which is responsible for much of the
confusion which now prevails regarding the significance of the
many pelvic affections. The constitutional bias presents itself in
various ways. Any one of the several forms of dyscrasiæ may
retard the convalescence. These are: tuberculosis, scrofulosis,
syphilis, Bright's disease, the various blood disorders, malaria,
etc. The innumerable symptoms which have long been defined
by that now indefinite term, scrofulosis, are legion. It also has
long served as a convenient name under which to conceal much
ignorance. Were it possible to trace so-called scrofulosis to its
original source, it is probable that the importance given by Hah-
nemann to syphilis, psora, and "sycosis," using these terms in
their broadest sense, would be better appreciated. At any rate,
there often exists an obscure element which perpetuates indefi-
nitely local lesions, especially the catarrhal diseases of the
genital tract. In whatever form this element presents itself, it
can be reached only by proper constitutional treatment.
It is, then, clearly the duty of the physician, in dealing with
the many gynecological affections, to differentiate cause from
effect, when it is possible so to do, and to conduct his treatment
accordingly.
CHAPTER IX.
GENERAL TReatment of GYNECOLOGICAL
DISEASES.
GENERAL CONSIDERATIONS
I have endeavored in Chapter VIII to show the important part
played by malnutrition in the causation of the diseases of women.
The reflex symptoms are as numerous and varied as the figures
of a kaleidoscope; hence, while they may serve as guides in
selecting a remedy, they are too changeable to justify the phy-
sician in discarding other methods of treatment. Many of these
symptoms can be relieved by local treatment alone, especially
if they are not of long standing; often they will vanish under
the administration of a properly selected remedy; but not infre-
quently it is absolutely necessary to combine with specific and
local medication certain methods of dietetic, hygienic, and gen-
eral treatment in order to relieve symptoms which may be either
the result or the cause of pelvic disease.
The general symptoms requiring special attention are the
following:-
I. Indigestion;
2. Constipation;
3. Nervous prostration.
I. INDIGESTION.
The stomach, as we have seen, is one of the first organs to
become deranged in a reflex way. Under certain circumstances,
as in some cases of pregnancy and hysteria, the stomach appar-
ently rejects almost every particle of food taken into it, without
seriously involving nutrition. In the vast majority of instances,
however, prolonged disordered digestion leads to inanition and
malnutrition, for, unless the patient can digest and assimilate the
proper amount and kind of food, depraved nutrition is inevitable.
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GENERAL TREATMENT OF GYNECOLOGICAL DISEASES. 125
The treatment of indigestion is considered under the sections
devoted to constipation and nervous prostration.
2. CONSTIPATION.
I am inclined to believe that the evils of constipation are
under-estimated in the homeopathic school. Too much reliance
is placed, by many, upon the indicated remedy, and too little
upon certain adjuvants which are both useful and harmless.
Constipation begets indigestion, headache, and local congestion.
It is many times impossible to cure an irritable ovary or a con-
gested uterus without first regulating the action of the bowels.
The frequency of constipation in women is proverbial. It is
much more common than in men, because of sedentary habits,
confinement in ill-ventilated rooms, and, above all, improper
conveniences. Habit in no small degree controls every function
of the body, and especially defecation. If Nature's commands
are ignored, she soon ceases to give them. In due time there is
a sensory paralysis of the mucous membrane of the rectum, and
the feces accumulate in large quantities without exciting the
involuntary mechanism. Finally, the hardened feces give rise
to fissure or hemorrhoids, and when pain becomes a factor
defecation is postponed as long as possible. America has much
to learn from Europe in making proper public provision for the
accommodation and protection of women when away from home.
In the treatment of constipation the first and essential requisite
is to secure the coöperation of the patient. Without this all
measures are futile. The habit must be reëstablished, and this
often requires much time and perseverance. She should direct
her thoughts to the necessity of the act at a certain hour each
day before retiring to the closet, which should be done with
clock-like regularity, whether the desire be present or absent.
This is indispensable. The best time for making this effort is
when the peristalsis is excited by a meal-preferably immedi-
ately after breakfast. Fullness of the abdomen favors defecation,
and a glass of water shortly before the act aids in producing a
feeling of distention. Severe effort at straining should be avoided.
The sense of leisure resulting from a proper position will encour-
age gentle instead of violent effort.
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A TEXT-BOOK OF GYNECOLOGY.
The diet and ingesta are of equal importance. As constipa-
tion is so often associated with indigestion, it becomes necessary
to select the diet accordingly. In doing this there are several
indications to be fulfilled: (a) the articles selected should not
distress the stomach; (b) they should be such as the patient
can afford; and (c) the cause of the constipation should be borne
in mind, i. e., whether due to deficient secretion or to deficient
peristalsis.
Fruits are almost always advantageous. The kind of fruit
should depend in a measure upon the cause of the constipation.
They act by increasing the distention; by increasing the secre-
tion because of their juices and acids; and by increasing peris-
talsis because of the fibers, rinds, seeds, etc., which drop into
the intestinal canal.
Apples are almost always to be had in this country and fulfil
the first two indications; if the rind is left on they excite peris-
talsis as well. They should be eaten in the fore part of the
day-before or after breakfast. The acid increases the intestinal
secretion, and they are therefore especially useful when the stools
are dry and hard. Oranges and lemons act in the same way.
Peristaltic action, when there is great torpidity of the bowels, is
quickened by fruits containing many seeds, as figs and the
various small fruits. Most of the berries improve the function
of the bowels because of the combined action of the seeds and
acids-hence they are particularly useful in season. Canned
fruits are apt to be too sweet, so that the uncooked varieties are
at all times preferable when they can be had. Stewed prunes
and baked apples are, however, often useful, and possess the
advantage of being inexpensive. Many patients cannot take
bananas because of the distress which they excite. Where
this is not so they are very useful, oftentimes acting as a
cathartic. On the whole, I much prefer acid to sweet fruits,
because they increase not only the intestinal secretion but the
hepatic as well.
The coarser breads are always beneficial, and the more bran
or hull of the grain they contain the better. Bran crackers,
such as are used in most sanatoriums, fulfil the indications nicely.
In the absence of these, and when the stomach will tolerate it,
GENERAL TREATMENT OF GYNECOLOGICAL DISEASES.
127
I have often seen a teaspoonful of bran in a glass of water,
drank the first thing in the morning, act in a most satisfactory
manner. Pop-corn is often most efficacious, and in the consti-
pation of pregnancy, with nausea and vomiting, it will sometimes
relieve the stomach symptoms when everything else fails. Oat-
meal and corn-meal gruels are likewise useful in exciting peris-
talsis.
If there be spasm of the sphincter ani muscle, with fissure or
hemorrhoids, nothing short of dilatation under ether will prove
of much avail. I know of nothing in the practice of gynecology
more satisfactory than this operation, when indicated.
Displacements of the uterus and ovaries may act in a mechan-
ical way and obstruct the bowel. Indeed, mechanical causes
should always be looked for in the treatment of costiveness in
women. Rectal stricture may act in the same way, but organic
strictures rarely occur in the female. I have had more than one
case brought to me with a diagnosis of stricture made because
of the constipation and the difficulty with which the inexperi-
enced sometimes meet in penetrating the "third sphincter."
In these cases forcible dilatation does much good.
In great torpidity of the large intestine massage is very use-
ful. Beginning at the right groin, and with a definite idea of
the anatomy of the parts, the whole colon can be kneaded and
squeezed in such a way as directly to stimulate its fibers to con-
tract. This is best done just before an effort is made to move
the bowels. At first this manipulation will excite much distress,
unless practised with great gentleness, but after a few treatments
it is not in the least disagreeable. In hydropathic institutions
much reliance is placed upon water compresses over the bowels.
I have no doubt of their utility under certain circumstances.
If the bowels absolutely refuse to move in spite of the best
directed general and local treatment, enemata will have to be
resorted to. If there are evidences of impaction, some solvent
may be used with the enema. Glycerin, olive oil, and ox-gall
are the best agents for this purpose. The latter should be
diluted with water (3j-Oj). I desire, however, to enter my pro-
test against the indiscriminate use of enemata. It is quite as easy
to make a "pauper of the rectum" by the use of the syringe
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A TEXT-BOOK OF GYNECOLOGY.
as by the use of cathartics. Of the two evils the former is the
lesser, though in non-surgical cases enemata are rarely necessary.
In gynecological practice cathartics are still more rarely called
for, except in abdominal surgery. They are then used in the
form of saline preparations for the purpose of promoting drain-
age through the intestinal canal.
Therapeutics.
Hydrastis Can.-Constipation with headache and hemor-
rhoids; AFTER STOOL, PAIN IN THhe rectum for HOURS; especially
useful after purgative medicines; colicky pains, with sensation
of goneness, faintness, and heat in the intestines. Much pros-
tration.
Collinsonia.-Constipation with hemorrhoids and a sensation
as of sticks in the rectum; stools consist of dry balls of fecal
matter; prolapsus uteri; flatulence and distention of the abdo-
men; heat and itching of the anus, with portal congestion;
HABITUAL CONSTIPATION.
Sulphur.-Abdominal plethora and passive congestion of the
venous system, causing a sensation of tightness and fulness in
the abdomen, with feeling of repletion after partaking of but a
small quantity of food (Farrington); constant urging to stool;
pressing on the rectum as if it would protrude; rush of blood to
the head; cold feet; faintness, especially at or about 10 or II
A. M.; stools hard and knotty; general dulness of mind and
body.
Nux Vomica.-Constant ineffectual urging to stool; alternate
constipation and diarrhea; sedentary habits; use of highly-
seasoned food; stools black, hard, and often streaked with blood;
hemorrhoids; RELIEF AFTER STOOL.
Lycopodium.-ABDOMINAL PLETHORA IN ELDERLY WOMEN,
WITH CONSTIPATION; large accumulation of gas in the bowels;
desire and inability to expel the stool, with painful constriction
of the rectum and anus; URIC ACID DEPOSIT IN THE URINE; irri-
table and restless in the afternoon.
Podophyllum.-Constipation, with descent of the rectum from
a little exertion; feces hard, dry, and voided with much diffi-
culty; flatulence and headache; MORNING AGGRAVATION OF ALL
GENERAL TREATMENT OF GYNECOLOGICAL DISEASES.
129
INTESTINAL SYMPTOMS; weakness and soreness of the back;
hemorrhoids.
Consult :-Alumina, opium, bryonia, graphites, anacardium,
conium, plumbum, sepia, silica, platina, pulsatilla, esculus
hip., calcaria carb.
3. NERVOUS PROSTRATION.
The terms nervous prostration and neurasthenia have, in Amer-
ica at least, become almost household words. There are many
factors capable of producing the state designated by these terms.
Sometimes it is met with when hematosis and nutrition are
seemingly unaffected; it is then usually due to nervous shock,
or strain, or to deficiency of the menstrual discharge. Oftener,
the mal-nutrition is prominent, which may be due to disordered
digestion, loss of fluids, or nervous shock.
The pathological succession frequently occurs in the following
order: A pelvic lesion involves the stomach in a reflex way, and
digestion becomes impaired; improper or insufficient food is
taken, and in due time nutrition is compromised; anemia and
chloro-anemia succeed as a matter of course, and not infrequently
are made worse by excessive menstruation. The nerve cells are
starved, as it were, for the want of proper nourishment, and the
nervous system is thereby rendered unduly impressionable. If
a woman thus affected be subjected to mental shock, or undue
mental strain and worry, or sexual excesses, she is liable to
become the victim of nervous prostration.
Any or all of the symptoms studied under the head of the
Hystero-Neuroses may be present in nervous prostration,
and their relative importance is there considered. In the treat-
ment of this state it becomes necessary to recognize the impor-
tant fact that the patient's nutrition is depraved, and if she is to
be raised from a state of chronic invalidism to robustness, this
must be improved. The backache, the leucorrhea, the menstrual
irregularities, the pain in various parts of the body, the paralyses,
and the psychoses are to receive due attention in a symptomatic
way. But the local trouble and the general disturbance result-
ing from depraved nutrition must not be ignored. With the loss
of appetite there comes wasting of fatty tissue, and the patient
9
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A TEXT-BOOK OF GYNECOLOGY.
takes to her bed, where, unless she can be made to eat and take
on flesh, she is likely to remain.
The profession is indebted to Dr. Weir Mitchell, more than to
any other man, for defining the principles upon which the suc-
cessful treatment of nerve prostration is based. These princi-
ples may be summarized as follows
1. Seclusion and Rest.-The patient should be removed from
home or other accustomed environments for at least six or eight
weeks, placed in bed, and only allowed to sit up gradually.
2. Massage. This is to be applied in a most thorough man-
ner by an experienced masseuse, the séances lasting for half an
hour at first, the time being lengthened until the full limit-an
hour and a half-is reached.
3. Electricity. The interrupted current is used twice daily,
and so applied as successively to work nearly all of the muscles
of the body twice daily.
4. Diet.—Milk is given every hour, at first in small quanti-
ties, then gradually increased until, under the action of massage
and electricity, the patient is able to take large quantities.
Dr. Mitchell practically ignores internal medication. From a
somewhat extended experience in this class of cases in both
hospital and private practice, I am satisfied that much good is
to be derived from properly selected homeopathic remedies.
It is surprising how quickly, under this treatment, the strength
improves, the lost adipose tissue returns, as well as the lost vital-
ity and the power of locomotion. The following case, recorded
by Playfair,* I quote in full, because of the acknowledged
eminence of the author, and also because it demonstrates most
forcibly the utility of the treatment even in the most desperate
cases. It is, too, a remarkable instance of the multiform phe-
nomena so characteristic of neurotic disease:-
CASE. "The case must be well known to many members of the profession,
since there is scarcely a consultant of eminence in the metropolis who has not seen
her during the sixteen years her illness has lasted, besides many of the leading
practitioners in the numerous health-resorts she has visited in the vain hope of
benefit. My first acquaintance with the case is somewhat curious. About two
months before I was introduced to the patient, chancing to be walking along the
* "Nerve Prostration and Hysteria," Playfair, p. 101.
GENERAL TREATMENT OF GYNECOLOGICAL DISEASES.
131
esplanade at Brighton with a medical friend, my attention was directed to a remark-
able party at which every one was looking. The chief personage in it was a lady
reclining at full length on a couch, and being dragged along, looking the picture of
misery, emaciated to the last degree, her head drawn back almost in a state of
opisthotonus, her hands and arms clenched and contracted, her eyes fixed and
staring at the sky. There was something in the whole procession that struck me as
being typical of hysteria, and I laughingly remarked, 'I am sure I could cure that
case if I could get her into my hands.' All that I could learn at the time was that
the patient came down to Brighton every autumn, and that my friend had seen her
dragged along in the same way for ten or twelve years. On January 14th of this year
I was asked to meet my friend, Dr. Behrend, in consultation, and at once recognized
the patient as the lady whom I had seen at Brighton. It would be tedious to relate
all the neurotic symptoms this patient had exhibited since 1864, when she was first
attacked with paralysis of the left arm. Among these-and I quote from the full
notes furnished by Dr. Behrend-were complete paraplegia, left hemiplegia, complete
hysterical amaurosis; but from this she had recovered in 1868. For all these years
she had been practically confined to her bed or couch, and had not passed urine
spontaneously for sixteen years. Among other symptoms I find noted awful suffering
in spine, head, and eyes, requiring the use of chloral and morphia in large doses.
For many years she had convulsive attacks of two distinct types, which were obviously
of the character of hystero-epilepsy. The following are the brief notes of the
condition in which I found her, which I made in my case-book on the day of my
first visit. I found the patient lying on an invalid's couch, her left arm, paralyzed
and rigidly contracted, strapped to her body to keep it in position. She was groaning
loudly at intervals of a few seconds from severe pain in her back. When I attempted
to shake her right hand she begged me not to touch her, as it would throw her into
a convulsion. She has now many times daily, frequently as often as twice in an hour,
both during the day and night, attacks of sudden and absolute unconsciousness, from
which she recovers with general convulsive movements of the face and body. She
had one of these during my visit, and it had all the appearance of an epileptic
paroxysm. The left arm and both legs are paralyzed and devoid of sensation. She
takes hardly any food and is terribly emaciated. She is naturally a clever woman,
highly educated, but, of late, her memory and intellectual powers are said to be
failing.
"It was determined that an attempt should be made to cure this case, and she was
removed to the Home Hospital in Fitzroy Square. She was so ill, and shrieked and
groaned so much on the first night of her admission, that next day I was told that no
one in the house had been able to sleep, and I was informed that it would be
impossible for her to remain. Between 3 P. M. and 11.30 P. M. she had had nine
violent convulsive paroxysms of an epileptiform character, lasting, on an average, five
minutes. At 11.30 she became absolutely unconscious, and remained so until 2.30
A. M., her attendant thinking she was dying. Next day she was quieter, and from
that time on her progress was steady and uniform. On the fourth day she passed
urine spontaneously, and the catheter was never again used. In six weeks she was
out driving and walking, and within two months she went on a sea-voyage to the
Cape, looking and feeling perfectly well. When there, her nurse, who accompanied
her, had a severe illness, through which her ex-patient nursed her most assiduously.
+
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A TEXT-BOOK OF GYNECOLOGY.
*
She has since remained, and is at this moment, in robust health, joining with pleasure
in society, walking many miles daily, and without a trace of the illness which
rendered her existence a burden to herself and her friends."
There is another and large class of neurasthenic women who
are well enough to be about, and the causes of their disease can
be corrected by fresh air and exercise. These cases exhibit the
entire range of mild mimetic and hysteric symptoms. Moral
advice, resolute will, and proper hygiene are often all that is ne-
cessary. Hysterical joints frequently present in this type of
patients. They are much more easily dealt with than the “ha-
bitually bed-ridden, couch-loving invalid," of whom Dr. Play-
fair's celebrated case is a typical example.
The amount of nourishment taken under the conditions de-
scribed is marvelous. Patients who are able at first to take
almost nothing at all, and as a result have become pale, anemic,
and wasted, will soon consume at each meal a quantity of food
which is simply astonishing. In one of Dr. Playfair's patients
the treatment was commenced on October 16th with three ounces
of milk every third hour. On October 30th the following was
consumed with relish: "5 A. M., ten ounces of raw meat soup;
8 A. M., cup of black coffee; 9 a. M., plate of oat-meal porridge,
with a gill of cream and a tumbler of milk; 12.30 P. M., milk;
1.45 P. M., whiting, bread and butter, rump-steak, cauliflower,
omelette, and a tumbler of milk; 4 P. M., milk; 5 P. M., milk and
bread and butter; 7 P. M., fried haddock, chicken, cauliflower,
apple and cream, and a glass of Burgundy; 9.30 P. M., milk; 11
P. M., raw meat soup. (The milk between 8 a. M. and 9.30 P. M.
amounted to two quarts.)"
•
It is possible for this amount of food to be consumed by a
nervously prostrated woman only under suitable conditions. By
seclusion she is cut off from all harmful sympathy and excite-
ment; by rest she conserves all her energies; and by massage
and electricity passive exercise is substituted for exertion with-
out any of its evils.
Proper seclusion can rarely be had at home because of the
close proximity to sympathetic relatives and friends. It is cer-
tainly impossible without a thoroughly good nurse-one pos-
sessing sufficient will-power to keep from the invalid's room all
GENERAL TREATMENT OF GYNECOLOGICAL DISEASES.
133
who exert a harmful influence. A greater degree of liberality
may be admitted in dealing with patients who retain the power
of self-control.
Massage, to be thoroughly done, should be applied by a
trained masseuse. It can, however, be easily learned by any in-
telligent person who is sufficiently strong. With the patient
lying in a blanket, the masseuse begins at the feet by taking up
the skin and thoroughly pinching it all over. The toes are
twisted in all directions and the small muscles kneaded with the
ends of the fingers and thumb. The large muscles of the legs
are grasped alternately with both hands. Dr. Mitchell recom-
mends smearing the parts with some nutrient lubricant, prefera-
bly cocoa butter. Striking the large muscles very often with
the palms of the hands constitutes an important feature of mas-
sage. The hands and upper extremities are manipulated in the
same way, working upward. In working the abdomen the
patient should lie flat on her back with the knees drawn up.
Commencing with the skin, it is pinched all over and the walls
are firmly grasped, first with one hand and then with the other.
The hands are now placed one on each side just below the ribs
and the flesh drawn forward in the direction of the colon. This
part of the treatment is particularly important if the patient is
suffering from indigestion. The posterior surface of the body
is gone over in the same way, the patient lying flat upon her
face and abdomen. The whole of the back is treated, com-
mencing at the nape of the neck and passing downward on each
side of the vertebral column.
The skin and muscles are pinched and the two fingers of the
right hand, one on each side of the vertebræ, are made to sweep
downward the entire length of the spine. This is to be repeated
a number of times. If there is spinal irritation there will be
some difficulty in doing this, but by gradually approaching the
sore spots they can be thoroughly treated, the local sensitiveness
being in time entirely destroyed. This is true in hyperesthesias
of other regions, and with perseverance and patience, even
ovarian irritation can be made to vanish. For the first two or
three days the séances should not be longer than twenty minutes,
but by the end of a week they may be continued from one to
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two hours twice a day. The patient must be taught to relax
all of the muscles by remaining perfectly passive.
The use of electricity comprehends the application of the
slowly interrupted induction current to nearly every muscle of
the body within reach. By this means they are thrown into
active contraction. This gives decided exercise to the muscles
and greatly supplements the action of massage. Finally, the
tonic effects of electricity are obtained by passing for ten or
fifteen minutes, from the neck to the feet, a mild current with
rapid breaks.
When fat and anemic women become victims of nervous
prostration it is Dr. Mitchell's practice to put them at rest, and
"under-feed" them with milk until the flesh is materially
reduced, when they are subjected to the usual treatment already
described.
The wisdom of local interference before placing a patient
under the rest cure must depend upon circumstances. As a rule
I believe it wise always to make a thorough examination, unless
the patient's nervous system is liable to be greatly shocked by
so doing. If, in married women, there are tears of the cervix
or perineum, which evidently play an important part in the pros-
tration, and if the degree of prostration is not such as to
prohibit it, an operation is indicated at once. This is emphat-
ically so if excessive hemorrhage can be controlled by repair-
ing the tears or by curetting. On the contrary, in the unmar-
ried, when the local symptoms are not urgent, it is best to ignore
local measures, other than the hot douche, until the patient has
regained sufficient strength to enable her to undergo such treat-
ment as may be necessary. There are but few instances where
the hot douche, judiciously given, does not act beneficially.
The remedy most homeopathic in nervous prostration will,
in the majority of instances, be one capable of profoundly
impressing the system when given in health. The various
phases of hysteria are covered by the milder remedies, but
when emaciation becomes marked, and hematosis seriously dis-
turbed, it is necessary to select a remedy profound in its action.
If properly selected it should not be repeated too often, nor
should it be changed until it is evidently no longer indicated. I
GENERAL TREATMENT OF GYNECOLOGICAL DISEASES.
135
prefer to base the prescription in these cases upon constitutional
symptoms, i. e., actual tissue changes, controlling, if necessary,
urgent nervous outbreaks or manifestations of pain with inter-
current remedies. However, if the chief remedy is properly
selected, the intercurrent one will rarely be called for.
Therapeutics.
Arsenicum Album.-Great fear, trembling, cold sweat, REST-
LESSNESS, and PROSTRATION; expression anxious and distressed;
face pale, yellow, waxy, with edematous swelling; dryness of
the mouth, with red streak down middle of tongue and redness
of the tip; loss of appetite, with INCREASED THIRST; long-lasting
nausea, with fruitless retching; VOMITING IMMEDIATELY AFTER
EATING OR DRINKING; menses too early, too profuse, and very
exhausting; WARMTH ALMOST ALWAYS RELIEVES THE PAIN.
Calcaria.-Depression and melancholia; apprehensive mood;
face pale, bloated, with blue rings around the eyes; after milk,
nausea and some eructations; water brash; after eating, press-
ing pain in the stomach, as if from a load or stone; hard disten-
tion of the abdomen; MENSES TOO EARLY, TOO LONG, AND TOO
PROFUSE; membranous dysmenorrhea; oppression of the chest ;
tendency to tuberculosis; COLD HANDS AND COLD FEET; relax-
ation of the tissues, with goneness and weakness. Calcaria is
oftener indicated in fleshy, anemic women than in the emaciated.
Ferrum.-Nervous, hysterical feeling; pettish; least contra-
diction angers; throbbing pain on top of head when moving
suddenly; FACE ASHY PALE OR GREENISH, BECOMING FIEry red
UPON THE LEAST EXCITEMENT; face pale, with red spots; pale-
ness of all the mucous membranes; vomiting as soon as food is
taken; diarrhea, with undigested food, or constipation, with
stools hard and expelled with difficulty; menses too late, long
lasting, and profuse; PALPITATION OF THE HEART, WITH THROb-
BING OF ALL THE BLOOD-Vessels; anasarca. The more clearly
BLOOD-VESSELS;
homeopathic iron is to any given case, the smaller the dose
required to accomplish the desired end. This is true of any
remedy, but preeminently so of iron. The fact remains that in
certain cases of anemia iron as a pabulum will do much to
improve the patient's condition when specific indications do not
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A TEXT-BOOK OF GYNECOLOGY.
present. Five or ten drops of ferrum dialysatum, twice or thrice
a day with meals, will often work wonders when the smaller
doses fail entirely. This dose is not large enough to precipitate
hemoptysis and subsequent phthisis, which has been done by
full doses.*
Iodium.—Excessive excitability; face pale, yellow, sallow,
and distressed; EATS FREELY, YET LOSES FLESH ALL THE TIME;
alternate canine hunger and loss of appetite; constipation alter-
nating with diarrhea; mammæ dwindle away and become
flabby; induration and swelling of the uterus and ovaries.
Ignatia.-Desire to be alone; nervous prostration following
excessive grief or joy; clavus hystericus, relieved by lying upon
the painful spot; head feels sore and bruised; choking sensation
extending from stomach into throat (globus hystericus); spinal
irritation; stiffness in the nape of neck; paralysis after great
mental emotion.
Phosphoric Acid.-Cerebro-spinal exhaustion from overwork;
"The least attempt to study causes heaviness, not only in the
head, but in the limbs."-Farrington. "Hysteria in women of
dark complexion during the change of life.”—Hering. Meteor-
istic distention of the abdomen with rumbling and gurgling;
painless stools; urine looks like milk (phosphatic), or clear and
passed in large quantities; menses too early and too long;
amenorrhea; ovaritis and metritis from debilitating influences.
Silicea.-Patient dreads any exertion either of mind or body;
numbness of the toes, fingers, and back; spinal irritation; VIOLENT
PERIODIC HEADACHE IN VERTEX, OCCIPUT, OR FOREHEAD, BETTER
BY WRAPPING THE HEAD UP WARMLY; constipation, due to inac-
tivity of the rectum; profuse, acrid, corroding leucorrhea;
increased sexual desire with spinal affection; night sweats.
Sulphur.-Face pale and eyes sunken; menses suppressed or
too late and of short duration; bearing down in pelvis toward
*"The treatment of anemia by iron is one of the few satisfactory and certain things
in modern medicine, and we who believe in the supreme value of the homeopathic
method may not neglect it because it does not seem conformable thereto, unless we
can do better. That we cannot is the general confession; we must, therefore, give
our anemic patients the iron they need, in whatever quantity may be necessary.'
Hughes.
11
麒
​GENERAL TREATMENT OF GYNECOLOGICAL DISEASES.
137
genitals; BURNING OF SOLES OF FEET AND WANTS THEM UNCOV-
ERED, or feet cold and sweating; heavy, unrefreshing sleep;
skin rough, scaly, or scabby, with itching; worse in a warm
bed.
Consult :-Lachesis, pulsatilla, sepia, aurum, picric acid,
china, cocculus, hyoscyamus, and lycopodium.
CHAPTER X.
LOCAL TREATMENT OF GYNECOLOGICAL
DISEASES.
GENERAL CONSIDERATIONS.
That local gynecological treatment has been and is now much
abused cannot be denied. This, however, is no more reason
why it should be discarded in toto than that internal medication
should be discarded because it has been and is now abused.
This statement is made with a full consciousness that there yet
exists a small party in the homeopathic school who not only
deny the necessity of any local treatment or measures whatever
in the treatment of the diseases of women, but even contend
that local examinations are unnecessary and reprehensible. I
do not desire to take issue with those who honestly hold this
view, other than to state that it does not seem to me, from
personal observation, that the interests of the school are best
subserved by such unlimited faith in the efficacy of the homeo-
pathic remedy. More than once I have had patients come to
me from the hands of physicians who ignore local exami-
nation and treatment, with cancer advanced beyond the
operative stage, and with long-existing local lesions which were
readily cured by local measures. I therefore do not hesitate to
affirm it as my belief that the physician who to-day, with our
knowledge of reflexes and malignant disease, refuses to grant
his patient the benefit of local measures when general ones have
failed, or declines to make a local examination if there is the
least suspicion of malignancy, is culpably remiss in his obligations
and should be held legally responsible for his neglect.
THE VAGINAL DOUCHE.
Only since the thermic properties of the vaginal douche have
been appreciated has it been systematically employed as a
therapeutic agent. It has long been used, however, for cleansing
138
LOCAL TREATMENT OF GYNECOLOGICAL DISEASES.
139
purposes, and although Dr. Eminet published some twenty years
ago the advantages to be derived from using large, hot douches,
there are yet many in the profession who do not comprehend,
simple as it is, the technique of a properly administered douche.
The simile used by Emmet is a good one for the purpose of
impressing the patient with the importance of using much water
and having it hot. It is the well-known blanched appearance
of the hands of a washerwoman after having them in hot water
for some time. When first immersed they become red because
the primary (temporary) action of the heat is to dilate the vessels
and.capillaries, thus causing congestion; in a short time the heat
contracts the vessels, drives the blood from them, and the hands
become white and shriveled. Contraction of the vessels is,
therefore, the secondary and more permanent action of heat;
the object to be attained in using a vaginal douche for thera-
peutic purposes is this secondary contraction.
This can only be accomplished by using water in large quan-
tities and at the proper temperature. The quantity should not
be less than one gallon, preferably two and often three. The
temperature should range from 95° to 120°, depending upon
the local condition and the susceptibility of the patient.
Indications. The douche, as a therapeutic agent, is indicated
in almost all conditions where pathological congestion is present.
Thus, in the various catarrhal and inflammatory affections of the
uterus and endometrium, in pelvic cellulitis and peritonitis, and
in vaginitis, its use is invaluable. For cleansing purposes it is
indicated whenever there is an offensive discharge from the
vagina and after menstruation. Large quantities of hot water
thrown into the vagina immediately preceding an operation upon
the uterus or vagina is an exceedingly valuable hemostatic, and
in plastic operations will prevent the loss of much blood.
Method.-When vaginal injections are given for therapeutic
purposes it is best to have such apparatus as will put the patient
to the least possible inconvenience. The most conscientious
are too apt to neglect any method of treatment which becomes
irksome. I therefore prefer some method of conducting the
fluid into the vagina which requires no physical effort. This
can be done either with a siphon syringe, or, better still, with
140
A TEXT-BOOK OF GYNECOLOGY.
a vaginal irrigator (Fig. 56). I have my dealer keep constantly
on hand a supply of these irrigators holding two gallons. They
can be made cheaply at any tin-shop, and are, therefore, inex-
P.H.SCHMID
NEW-YOR!
FIG. 56.
VAGINAL IRRIGATOR.
pensive. The rubber tubing should
be at least six feet long, and should
possess a clip or cock by which
the stream can be controlled. The
nozzle should be of hard rubber
and perforated at the sides only.
If there is an opening at the center
there is great danger of water
passing into the uterine cavity.
If made of metal it becomes
heated by long contact with the
hot water. Emmet maintains that
an interrupted current, such as is.
derived from any of the bulb
syringes, is more effective. If so
its advantage is more than offset
by the exertion necessary to force
a large amount of water into the
vagina.
In taking the douche the patient should lie upon her back
with the hips somewhat elevated. The advantages of this posi-
tion are the outlet of the vagina is higher than its vault, so
that the canal is completely distended by the fluid; the hips are
higher than the trunk proper, so that gravitation aids in relieving
the venous congestion. It becomes necessary in this position
to make some provision by which the fluid can be taken care of
after it passes from the vagina. If economy is an object, this
can be accomplished by placing the patient across the bed, her
hips projecting well over the side and her feet resting upon two
chairs. By placing a rubber sheet under her and properly
shaping it, the water is conducted to a receptacle on the floor.
A regular douche pan is, however, always to be preferred when
obtainable.
Beginning with a temperature of 95° F., it can be gradually
increased by adding hot water until the maximum, 120°, is

LOCAL TREATMENT OF GYNECOLOGICAL DISEASES.
141
reached. It should not be used hotter than this, and when the
treatment is first begun it is well to advise the patient not to
exceed 110° for the first few treatments, because occasionally
the douches cause some sickness when too hot. The nozzle
should be inserted well into the posterior fornix, behind the
cervix. Unless this precaution is taken there is danger, if the
os is patulous, of passing it into the cervical canal. The irrigator
should be suspended at least three feet higher than the body in
order to insure the necessary force.
The size of the douche and the frequency of its repetition
must necessarily depend upon circumstances. As a general
rule, when used for therapeutical purposes, twice a day, the last
given just before retiring, is not too often, and two gallons of
water each time not too much. For hemostatic purposes three
and even four gallons should be used. After a douche of this
kind the mucous membranes exposed to the water will be found
almost white and bleed but little when cut. For disinfecting
purposes a much smaller quantity of water is required—enough,
however, to cleanse the parts of all fetor.
I do not advocate the vaginal douche in the treatment of the
diseases enumerated, as a cure-all. It is to be looked upon only
as an adjuvant though a most important one.
I often pre-
scribe it in the leucorrhea of virgins and young girls when an
examination is not imperative, and frequently this is all that is
necessary in the way of local measures. But to prove effective
the patient must be impressed with the importance of observing
the proper quantity and temperature of the water, the proper
position, and, above all, of persevering for weeks or months.
The thermic qualities of a vaginal douche are undoubtedly
the most important from a therapeutical standpoint. Much good
may be accomplished by adding to the water some medicament,
-hydrastis, calendula, eucalyptus, etc.,-depending upon the
indications which present. When special indications for any par-
ticular remedy exist it is my custom, especially if no other form
of local treatment is being pursued, to add a tablespoonful of
the agent selected to the last pint of water used, instructing the
patient to lie upon her back for fifteen or twenty minutes that
the remedy may remain in contact with the diseased parts for
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A TEXT-BOOK OF GYNECOLOGY.
that length of time. Antiseptic and disinfecting injections are
composed of: carbolic acid, 1-200; bichlorid of mercury, I–
4000; permanganate of potash, 1-100; bicarbonate of soda,
I-20; and salicylic acid, 1-1000.
Counter Indications.-Nothing more than a cleansing
douche should be given during pregnancy, for obvious reasons.
However, the mortal fear which some women have of throwing
even a small quantity of water into the vagina while pregnant is
absurd. Of course, if there is a predisposition to abortion the
pregnant woman cannot be too cautious, but, in the vast majority
of instances, nothing but good results will follow the occasional
use of a small tepid douche. This is particularly so if there
exists an irritating leucorrhea. The douche should not be used
during normal menstruation. When the menstrual discharge is
excessive because of actual disease it can then be administered
for its hemostatic properties. This treatment is invaluable in
dealing with hemorrhage the result of fibroma uteri. A cleans-
ing douche should, however, follow the cessation of the men-
strual flow if there be any fetor.
LOCAL APPLICATIONS.
There is nothing which more confuses the average student
than the question of local applications in the treatment of gyne-
cological diseases. This is owing to the fact that, even in the
homeopathic school, each author and teacher has his favorite
local remedy or remedies, and, unfortunately, empiricism is yet
rife in the use of most of them. As a rule, the physician will
accomplish more by learning how to use intelligently a few well-
selected applications and confining himself to them, than by at-
tempting in an aimless fashion to run the whole scale. In ordi-
nary routine work I rarely have occasion to go outside of the
following list:-
Glycerin;
Boro-glycerid;
Iodin (compound tincture);
Hydrastis ;
Calendula ;
Carbolic acid.
:
LOCAL TREATMENT OF GYNECOLOGICAL DISEASES.
143
I think that I have learned how to use these agents. Their
special indications will be mentioned in discussing the various
lesions in which they are useful, and it is only necessary in this
chapter to deal in a general way with their properties and the
method of their application.
Glycerin.-Glycerin, in technical parlance, is designated a
hydragogue, because of its power to produce a free watery dis-
charge from mucous surfaces. In hyperemia of the pelvic
organs and in inflammatory conditions, whether subacute or
chronic, it relieves the congestion by extracting from the blood
its serum. In almost every application to the cervix and the
vagina, glycerin is used either as a vehicle with which to mix a
more active remedy, or for the purpose of medicating the tampon
which is finally to be introduced. It is a most important auxiliary
to the vaginal douche. The best method of applying it is through
a speculum, with tampons of cotton-wool well saturated with it.
These should be inserted daily, and the nurse should, therefore,
be instructed how to introduce them. Various instruments have
been devised for the purpose of enabling the patient to intro-
duce them herself, but all are more or less unsatisfactory. In
multiparæ it is often possible to pass a medium-sized tampon
through the ostium vagina without the aid of any instrument.
Boro-glycerid.—This preparation is made by adding to four
fluidounces of glycerin one ounce of powdered borax and rub-
bing them well together in a mortar until the borax is thoroughly
dissolved. I first began to use this remedy upon the recom-
mendation of Dr. Wylie of New York. The borax seems to
intensify the action of the glycerin in hyperplasia with much
induration, or else it exerts its own action upon tissues thus
affected. At any rate, it seems more efficacious than pure
glycerin, where the products of inflammation are felt through
the fornices and where there is hyperplasia and subinvolution,
with acrid leucorrhea and exaggerated menstrual discharge. In
aphthous ulceration of the vagina or cervix-a rare disease in
adults it is almost a specific. Boro-glycerid is also an anti-
septic of no mean value.
Iodin. Churchill's tincture is the preferable preparation.
It consists of seventy-five grains of iodin and ninety of iodid
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A TEXT-BOOK OF GYNECOLOGY.
of potassium to the ounce of alcohol. Iodin applied to the
congested cervix and vaginal mucous membrane acts upon the
capillaries, causing their contraction, and upon the lymphatics,
stimulating them to absorb the exudation of plastic lymph in
pelvic inflammations and the hyperplastic tissue in areolar
hyperplasia. Its use is, therefore, indicated in subinvolution
with or without hyperplasia, in inflammatory deposits, in chronic
ovaritis when the ovary is enlarged and prolapsed, in chronic
corporeal endometritis, and in cervical catarrh with abrasion.
It may be applied directly to the cervix, the corporeal mucosa,
or the vault of the vagina. It is best applied to the cervix by
means of an applicator properly wrapped in absorbent cotton.
The cervix should be previously cleared of all discharge. Any
excess of iodin should be expressed by pressing the applicator
against the side of the bottle. The whole vault of the vagina
may be painted with the drug in the same way. Caution
should, however, be exercised in the intra-uterine application of
iodin. I rarely use it unless the os is patulous and drainage
perfect. It should then be applied by carrying the applicator
well up to the fundus, permitting it to remain for a minute or
two. This enables the uterus to contract upon the cotton,
bringing the medicament into contact with its entire lining
inembrane.
Iodin, in the cases enumerated, should be applied from one
to three times a week. Instead of making direct application in
the manner described, it may be diluted with glycerin (1-4)
and applied upon a tampon. Indeed, if there is much hyper-
plasia, and rapidity of action is important, it is advisable to
introduce a tampon thus saturated instead of using one dipped
in pure glycerin or boro-glycerid. The tampon can be left in
the vagina from twelve to twenty-four hours. As a general
rule I prefer making the direct application of the iodin, supple
menting its action with the boro-glycerid tampon.
The proper application of iodin is painless. Pain may result
from contact of the drug with the skin surface by awkward
manipulation. This is immediately overcome by the application
of glycerin. If the patient at her next visit complains of
having experienced some distress, and if the tampon removed
LOCAL TREATMENT OF GYNECOLOGICAL DISEASES.
145
is blood-stained, it is well to lengthen the intervals between the
treatments, or the iodin may be diluted by adding glycerin.
In the preparatory treatment preceding trachelorrhaphy in
cases where there is much hyperplasia I rely largely upon the
hot douche, the compound tincture of iodin, and the boro-
glycerid tampon. Under this treatment it is surprising how
quickly hyperplastic tissue will melt away. The pressure exerted
by the tampon is a curative factor soon to receive attention.
Hydrastis Canadensis.-The chief indication for the local
use of this drug is a profuse, stringy leucorrhea, with extensive
glandular involvement. It is especially useful where the consti-
tutional symptoms suggest its internal administration as well.
As an intra-uterine application in chronic endometritis it is both
safe and beneficial. A very serious objection to the drug as a
local measure has been its staining properties. Pharmacists
have now overcome this by the production of a colorless extract
which seems quite as efficacious as is the original preparation.
Hydrastis may be applied directly to the parts by the aid of
an applicator, after which a tampon saturated in hydrastis and
glycerin (1-4) should be placed against the cervix. By so doing
it is longer in contact with the diseased parts-an important
consideration, particularly if vaginitis complicates the endo-
metritis, as it so frequently does.
Calendula.-Calendula is to purulent endometritis with erosion
what hydrastis is to glandular involvement with a tenacious,
stringy discharge. The cervix has a red, corroded, granular
appearance, due to solution of continuity, which gives rise to a
purulent leucorrhea. It is questionable whether or not calendula
exerts any power as an antiseptic.* It at least acts admirably
in suppurating wounds of all kinds, and in purulent conditions
is the sheet anchor of many homeopathic physicians. South-
wick says: "Following some surgical operations, after the
patient has used the ordinary cleansing douche, I direct her to
mix two teaspoonfuls of the tincture with half a pint of warm
water, to inject it while lying on her back, and retain it
ΙΟ
*I do not believe that calendula is a germ destroyer.
+" Practical Gynecology,” p. 39.
!
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A TEXT-BOOK OF GYNECOLOGY.
from twenty minutes to half an hour. The non-alcoholic
preparation is preferable.”
In chronic endocervicitis Cowperthwaite* recommends the
following: Hydrastis, one ounce; calendula, one ounce; glyc-
erin, four ounces. Of this a tablespoonful is diluted in four
ounces of water and used as an injection once or twice a day.
This was also a favorite prescription of the late Dr. A. I. Sawyer.
Personally, I prefer to use the remedies singly.
Carbolic Acid. This agent is an old and well-tried disinfect-
ant, and its use is limited to disinfecting purposes by many
physicians. As such, it is used in the form of a douche, the
strength varying from one to five per cent. Carbolic acid is,
however, something more than a mere disinfectant. It is, in
addition, antiseptic and anesthetic in its action. As an antiseptic,
I am in the habit of swabbing the cervical canal with the
"impure" acid before the minor operations upon the cervix or
the uterus. But it is its anesthetic properties which seem to me
the most valuable. When there is great hyperesthesia of the
mucous membrane at the internal os-which may exist in women
of all ages, but is oftener met with at or about the change of life
—a thorough application of carbolic acid, even though dilatation
is not practised, will often relieve distressing nervous symp-
toms in a most remarkable way. An occasional application of
the acid to an eroded cervix will act as a mild stimulant, supple-
menting the action of iodin and other remedies when they have
seemingly ceased to do good. After curetting in fungoid endo-
metritis, the impure acid should be applied to the entire endo-
metrium.
In the ordinary run of cases these remedies cover nearly every
indication and have the advantage of being both mild and harm-
less in their action. However, this chapter would be incomplete
without considering those less often called for.
*" Text-book of Gynecology," p. 165.
+ Impure or commercial carbolic acid, as prepared by Dr. Squibb, is not a caustic,
as is the pure.
LOCAL TREATMENT OF GYNECOLOGICAL DISEASES.
147
ASTRINGENTS AND STYPTICS.
Tannin.—The one indication for tannin can be summed up
in the word "relaxation." In rectocele and cystocele, with sub-
involution of the vaginal walls, the application of tannin, as
recommended by Mundé, is most useful. He applies it by dip-
ping a glycerin tampon into the powdered tannin.
It is styptic
as well as astringent in its action, and is therefore useful in vas-
cular conditions of the cervix and vagina.
Alum. This is also an astringent, and is used by many
specialists in preference to the tannin where there is much relax-
ation of the parts. I do not believe that it possesses any specific
properties when used locally. Its greatest sphere of usefulness
lies in its power to control hemorrhage after plastic operations
which cannot be controlled by ordinary hot injections. Used
as a saturated solution it is most effectual, and possesses the
advantage of not forming clots, as does iron.
Iron. When iodin, tannin, or alum fail to control hemor-
rhage, iron, in the form of persulphate or perchlorid, will have
to be resorted to. The large clots which it forms makes it an
undesirable, if not a dangerous, hemostatic to use within the
uterus. Nevertheless, it is sometimes necessary to utilize its
more powerful styptic properties in cases of intractable hemor-
rhage.
NARCOTICS.
Chloral Hydrate.-A solution is prepared by dissolving
one drachm of chloral hydrate in one ounce of glycerin. In
cancer of the cervix a tampon saturated in this and applied
directly to the ulcerated surface will often afford marked relief.
Opium. The aqueous extract may be used in carcinoma
uteri. It should be applied directly to the parts by means of an
applicator or upon a tampon.
Conium mac.-Conium is useful in cancer of the uterus,
particularly if indicated internally, where there is much infiltra-
tion of tissue with induration. It is a favorite remedy of many
homeopathic physicians for the relief of the shooting, darting
pains which so frequently attend cancer in any part of the body.
Belladonna.-Belladonna exerts a specific influence in acute
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A TEXT-BOOK OF GYNECOLOGY.
and subacute inflammatory lesions of the pelvic organs when
the distress is aching and throbbing in character. It may be
used as a cerate (one drachm to one ounce of vaseline) or in the
form of the fluid extract.
DISINFECTANTS.
Iodoform.-Iodoform is also both antiseptic and anesthetic
in its action. My chief use of this valuable agent within the
vagina is after plastic operations. It may be sprinkled upon
a glycerin tampon and thus applied, as a strip of iodoform
gauze may supplant the ordinary tampon.
Eucalyptus Globulus.-Eucalyptus is frequently combined
with hydrastis, or it may be used by diluting one drachm of the
oil in one ounce of glycerin. This is applied in the ordinary
way when there is an offensive discharge from the vagina from
whatever cause.
Boracic Acid.—A boracic acid lotion of the strength of two
drachms to the pint of water makes an excellent application in
pruritus vulvæ from whatever cause. It may be applied to the
cervix in the form of powder, through a powder blower, where
erosions exist. This is also a convenient way of applying iodo-
form.
CAUSTICS.
I have practically discarded the use of caustics in gyneco-
logical work, and am sure that my patients are the better for it.
The use of caustics about the cervix is, I believe, wrong in
principle. Terminal nerve filaments can be squeezed quite as
well by the cicatrix of caustics as by the cicatrix of tears.
There has been no greater curse to womankind than nitrate of
silver. By its use abrasions and ulcerations of the cervix may
be healed, but it is done at the sacrifice of that principle which
to-day is so well recognized as the essential one in the practice
of gynecology. I have more than once met with the most
obstinate reflexes which followed in the train of its use. The
powerful solutions recommended in virulent vaginitis are, I
believe, unnecessary and may do harm. At least one case of
adhesive vaginitis has come under my observation, the result of
LOCAL TREATMENT OF GYNECOLOGICAL DISEASES.
149
such an application. When a caustic is needed for surgical
purposes the actual cautery is by all odds preferable to nitrate
of silver, chloride of zinc, or the more powerful acids.
THE VAGINAL TAMPON.
The use of the vaginal tampon as a carrier of medicinal agents
has already been referred to. The material from which it is made
is not altogether unimportant. There is nothing which excels
the cotton-wool now on the market. It is soft, elastic, and never
"balls up," as does the ordinary cotton. Unfortunately, it is
rather expensive, but I am sure that when intra-vaginal pressure
is an object, as it is in dealing with inflammatory exudates and
hyperplasia, the extra cost is more than compensated for by the
superiority of the tampon thus made. If, on the contrary, pres-
sure is not important, the ordinary cotton or absorbent cotton
may be used instead. Tow or marine lint, lamp-wicking (Fos-
ter), the roller bandage, and sponges have all been used and
have their advocates. Except in cases of emergency I do not
think that the use of sponges for tampons is justifiable.
Cotton can be made into any desired shape, depending upon
the use for which the tampon is intended. If its function is
merely to keep a medicament in contact with the cervix, it should
be soft, of disk-shape, and the string loosely tied about it. If, on
the other hand, it is to support the uterus, it should be more
compact and cylindrical. Cylindrical tampons can be quickly
made in large numbers by spreading out a roll of cotton-wool
or cotton (the ordinary unglazed commercial cotton is nearly if
not quite as good for this purpose as the absorbent), and again
winding it tightly into rolls about one inch thick; loops of
strings are placed at intervals of two inches, between which the
roll is cut. This will make a number of tampons one inch thick
and two inches long-a very good size for the vaginal pouches.
The string should be sufficiently strong to guard against
breaking.
Indications.-The vaginal tampon is used-
1. As a carrier of medicament to be applied to the cervix or
vagina;
2. To control hemorrhage;
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A TEXT-BOOK OF GYNECOLOGY.
3. In uterine and ovarian displacements;
4. To retain other bodies in utero, such as stem pessaries,
tents, etc.;
5. After operations.
1. As a Carrier of Medicaments.-The soft glycerin plug is the
most serviceable tampon for this purpose. By spreading out a
sufficient quantity of cotton-wool on the palm of the hand a
large quantity of glycerin can be poured into it before shaping
the tampon, which can be conveyed into the vagina without
soiling the fingers or the clothing of the patient. Any other
substance may be added to the glycerin. This is applied directly
to the diseased parts. A dry roll of cotton should be placed
below this to keep it in position.
2. To Control Hemorrhage.-All clots should be first removed,
and, if the exigencies of the case are not too great, the vagina
thoroughly cleaned with a bichlorid solution (1: 3000). Soft
cotton tampons soaked in carbolic solution (1:200) are first
firmly packed with the dressing forceps into all of the fornices
of the vagina. Another plug is next placed directly over the
external os, after which the vagina is packed to its utmost limit.
The vaginal tampon should not be used in hemorrhage from
abortions after the fourth month. The cotton may be medicated
with some astringent-iron, tannin, or alum-instead of soaking
them in the carbolic solution.
3. In Uterine or Ovarian Displacements.-There are many
patients suffering from these displacements, particularly ovarian,
who can tolerate no other form of support. Preparatory to
the introduction of a permanent pessary the vaginal tampon is
often necessary. In retroversion a cylindrical tampon is first
passed into the anterior fornix, so as to push the cervix back-
ward and the fundus forward. One or two more, depending
upon the capacity of the vagina, are placed against this to
retain it in position. In anteversion the same number are
introduced into the posterior fornix. In both retro- and ante-
flexion the supporting tampon must be placed into that fornix
which is impinged upon by the fundus. In flexures the relief
afforded by tampons is due more to the elevation of the entire
uterus than to the straightening of its axis. In ovarian dis-
LOCAL TREATMENT OF GYNECOLOGICAL DISEASES. 151
placement a soft, medicated tampon is placed against the
diseased organ.
4. To Retain Other Bodies in Utero.-When a stem pessary is
introduced after dilatation, or when tents are introduced for the
purpose of dilatation, a tampon is necessary to retain them in
position.
5. After Operations.-In plastic operations, especially upon
the cervix, a large tampon smeared with glycerin and iodoform
should be placed in such a way as to relieve the sutures from
tension while the patient vomits. A strip of iodoform gauze
may be used instead, and for this purpose is even preferable.
Vaginal tampons can be inserted through any form of specu-
lum, though Sims's is by all odds the preferable instrument where
hemorrhage is to be controlled. In removing the speculum the
tampon, or tampons, should be held in place with the dressing
forceps. If introduced for the purpose of controlling hemor-
rhage they should not be left in longer than eight or ten hours,
for, no matter how carefully prepared, they soon become offen-
sive and irritating. When resorted to for the purpose of exert-
ing pressure or support they may be retained for twenty-four
or even forty-eight hours. In all instances their removal should
be followed by an antiseptic douche.
The patient should always be instructed how to remove
them. Traction should be made backward in the direction of
the perineum instead of forward. Where more than one is
introduced the patient or the nurse should be told the number;
they are then removed in the order indicated by the number of
knots in each of the cords. When used to control hemorrhage
the physician should remove them through a Sims speculum.
CHAPTER XI.
ELECTRICITY IN GYNECOLOGY.
Electricity as a therapeutic agent has for many years been
used more or less extensively by the vast majority of the
medical profession in the treatment of general diseases. In the
treatment of gynecological affections it has not been so com-
monly used. This is probably due to three reasons: (a) A
general knowledge of the physics of electricity does not pre-
vail. (b) It is generally believed that elaborate and costly
apparatus is necessary for its successful application. (c) In its
application in the diseases of women the absence of specific
indications makes precision difficult.
(a) While a profound knowledge of the physics of electricity
is under all circumstances desirable, it must be remembered
that, unlike the neurologist, the gynecologist deals with organs
closely grouped together in the pelvis; and that instead of
applying the agent for its effect upon nerves and the reaction of
muscles, he applies it to overcome perverted nutrition, hyper-
esthesia, and local congestion. It is, then, only necessary for the
gynecologist to understand the peculiar properties of the cur-
rent which he may wish to use, and to know which pole of the
galvanic current will produce irritation, which one absorption,
sedation, anesthesia, etc.
(6) For all ordinary gynecological work costly apparatus is a
luxury, but not a necessity. One can get on very well with a
good battery, and a few special electrodes. For the application
of the very powerful galvanic currents (which are not so much
used as formerly), a powerful battery together with a milliam-
pèremeter, rheostat, etc., is necessary.
(c) In undertaking to formulate specific indications in the
schema appended, I have drawn largely from the writings of
Grandin, Rockwell, Mundé, Massey, King, F. H. Martin, and
152
ELECTRICITY IN GYNECOLOGY.
153 -
Apostoli. In it I have endeavored to reflect in small compass
the more generally accepted rules, in order to simplify the appli-
cation of electricity in the treatment of the diseases of the
female pelvic organs. In those instances in which there is a
conflict of opinion I have been, in large measure, governed by
the weight of authority as well as by personal experience.
The reader is referred to the several excellent text-books
mentioned in the foregoing paragraph for theoretical amplifica-
tion and exhaustive detail. As the galvanic and the faradic
currents are the ones oftenest used in routine gynecological
work, it is only necessary in this chapter to define what is meant
by them, and the apparatus by which they are generated,
referring but briefly to the Franklinic current.
GALVANISM.
The galvanic current is generated by the decomposition of
two dissimilar metals immersed in some fluid. It is continuous,
chemical in its action, and starts from the affected plate toward
the one least affected. The plate least affected, therefore,
receives the electricity and gives it off at its external extremity,
and is known as the positive pole; the external extremity of the
plate most affected is known as the negative pole.
The action of these two poles is very different when applied
to living tissue, and the intelligent application of galvanism
requires a knowledge of this difference. The following are the
essential properties of the two poles:
The positive pole is anesthetic, the least painful, and its tendency
is to check hemorrhage and cause absorption.
The negative pole is irritating and caustic in its action. It is,
therefore, more painful than the positive and its tendency is to
produce hemorrhage and destroy. (Grandin.)
If the destructive currents are used the difference in the cica-
trices produced by the two poles is important. According to
Apostoli the cicatrix formed by the positive pole is hard and
retractile; while that produced by the negative is soft and non-
retractile.
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A TEXT-BOOK OF GYNECOLOGY.
FARADISM.
The faradic current, unlike the galvanic, is interrupted and is
chiefly mechanical in its effects. If it possesses any chemical
action it is very slight, and in gynecology it is used chiefly to
stimulate the uterus by virtue of its power to induce muscular
contractions.*
The faradic current is thus generated: An insulated conjunc-
tive wire of a galvanic battery is coiled on itself and laid on an
insulated surface. Around this is placed another coil of insu-
lated wire in which instantaneous currents are induced by the
galvanic current passing through the inner coil. From the first
of these coils of insulated wire the primary current is derived;
from the second, the secondary. The two together constitute
the helix. A bundle of soft iron wire placed in the center
of the helix greatly intensifies the current derived from the
induction coil. "When the current of the generating cell passes
through the helix the soft iron is magnetized and draws the
interrupter (rheotome) in contact with it. This breaks the circuit
and demagnetizes the iron. The interrupter is then returned to
its former place by a spring. This step reconnects the generat-
ing cell with the helix, and again allows the iron to be
magnetized. The interrupter is again drawn in contact with it.
Thus the current is constantly broken and restored by a simple
device known as an 'interrupter,' or ' automatic circuit-breaker.”
An induced current within the iron core of the helix is thus
produced. This is the current which passes through the elec-
trodes to the patient.Ӡ
The difference in the action of the two poles is not nearly so
marked as in the galvanic current, though the positive is more
sedative and the negative more stimulating. The primary or
inducing current is more useful in stimulating muscular con-
traction where sedation is not important; the secondary, or
induced current, is more useful where sedation is called for.
* The sedative properties of the secondary faradic current are now known to be
most useful in relieving pelvic pain.
† Ranney, “Electricity in Medicine," 1885, p. 5.
ELECTRICITY IN GYNECOLOGY.
155
THE FRANKLINIC CURRENT.
I find the franklinic current exceedingly useful in the treat-
ment of nervous prostration with spinal irritation and hysterical
pains in various parts of the body. No disturbance of the
clothing is required in its application unless the wet electrodes
are used. The sparks are induced by a self-charging plate
rotation multiplier. The voltage of each spark induced is very
great, depending upon its length-according to Thompson,
fifty-three thousand volts per centimeter. While the quantity
of electricity conveyed by the sparks is exceedingly minute
they are capable, because of the great pressure at which they
are delivered, of powerfully stimulating the cutaneous nerve
terminations. The sensation elicited where the sparks strike
the skin is that of a needle-thrust. The superficial muscles are
also more or less excited, especially if the wet electrodes are
used.
APPARATUS.
In the selection of a galvanic battery two essentials are im-
portant: it should contain a sufficient number of elements to
produce a current strong enough for routine gynecological
work; and the elements should be so constructed as to require
the least possible attention.
There are many excellent batteries on the market and but
few really poor ones. The chlorid of silver dry-cell galvanic
batteries are rapidly gaining in favor, as there is no fluid to spill,
and they require but little attention. They are made by the J.
A. Barrett Company, of Baltimore.
Of the fluid batteries infinite varieties are on the market.
The McIntosh and the Waite and Bartlette are old and well
tried instruments. It is claimed that the high internal resist-
ance and low electro-motive force of the Dry-cell makes it less
desirable for gynecological work. The objection will, in time,
undoubtedly be overcome.
It is quite as difficult now-a-days to obtain an inferior faradic
battery as an inferior galvanic.
The Kidder Tip-cup battery and the McIntosh are very
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A TEXT-BOOK OF GYNECOLOGY.
popular. I have in constant use McIntosh's "Little Gem"
Cabinet Battery, Waite and Bartlett's thirty-cell portable
galvanic battery and the Atkinson Four-plate Töpler static
machine, and have every reason to be satisfied with all.
GALVANOMETER.
The accurate application of galvanism is not possible without
some means by which the intensity of the current can be
measured. It is true that the number of cells brought into the
circuit is something of a guide, but inasmuch as there exists
such a marked variance in the internal and external resistance,
this is a rough and very inaccurate method, when a very
strong current is used. An instrument for this purpose is known
as a galvanometer or milliamperemeter.
A milliampère is the unit of electrical measurement, and for
routine gynecological work from five to forty milliamperès are
quite sufficient. Most milliampèremeters now made are capable
of registering intensities as high as one thousand milliampères.
WATER RHeostat.
The rheostat is an instrument devised for the purpose of
modifying the intensity of the current of electricity by passing
it through resistance coils or water. This is almost indispensable
in treating the organs of special sense, the brain, etc., and the
gynecologist will likewise find it of special utility. The water
rheostat is the simplest and most practical, and in it the cur-
rent is regulated by the distances between the ends of the
metals which are immersed in the water.
ELECTRODES.
The instruments by which electrical currents are applied to
the body are called electrodes. In their application to the
pelvic organs special electrodes have been constructed. They
are external and internal.
The ordinary external electrode consists of a handle to which
is attached a metallic plate covered with a sponge. The sponge
is, however, unsatisfactory, uncleanly, and not a good conductor.
The plates of sheet-lead or block-tin are much preferable in
ELECTRICITY IN GYNECOLOGY.
157
gynecological electrotherapy, being readily adapted to the
external surfaces of the body because of their pliability. They
can be covered by any inexpensive material of good conducting
quality (chamois, absorbent cotton, rough toweling, etc.) which
can be quickly changed for each patient.
The size of the external electrode should be governed by the
intensity of the current used. Manufacturers are apt, unless the
size is specifically stated, to furnish those which are altogether
too small. When very powerful currents are used, i. e., currents
of over sixty milliampères, they should be dispersed over as
large an area externally as possible. To accomplish this
Apostoli uses potter's clay with which to cover the abdomen,
and Engelmann plates of sheet-lead of the following dimen-
sions: 3½ x 4½ inches; 4½ x 64 inches; 6½ x 9½ inches.
These can be applied over the abdomen or back while the
patient is in almost any posture.
The object of internal electrodes is to utilize the several
cavities within the pelvis in order to more effectually localize
the electric current. They are, therefore, made to adapt them-
selves to the cervix, uterus, vagina, rectum bladder, etc. When
the positive pole is used direct within the uterus the electrode
should be of platinum. Dr. F. H. Martin has devised for the
purpose a very ingenious, flexible electrode.
GENERAL CONSIDERATIONS.
By the term direct application is meant the application of the
one or the other pole directly, or as nearly so as possible, to the
organ or organs diseased. This is accomplished by selecting a
proper internal electrode (vaginal, uterine, urethral, rectal, etc.),
the other pole being applied externally, usually over either the
abdomen or the sacrum; or by the concentration of the current
through the medium of a bi-polar electrode.
By the term indirect application is meant the application of
both poles externally, one electrode usually being placed over
the abdomen and the other over the sacrum. In young unmarried
women, unless the symptoms are urgent, it is advisable first to
resort to this method.
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A TEXT-BOOK OF GYNECOLOGY.
The conductivity of electrodes is increased by dipping them
in warm water, and the superficial revulsive effect of the galvanic
current is increased by using for this purpose salt water.
The time, length, frequency, intensity and manner of the
applications will necessarily vary with each case. The séances
should last from five to thirty minutes. For routine work I
rarely exceed fifty milliampères, and often use only five or ten.
Due regard must be paid to the function of menstruation, and
should there be any acute or subacute inflammatory symptoms,
direct electrization, at least, should not be practised for the first
few days preceding or following the expected period. In amen-
orrhoea, on the contrary, the molimina should be watched for,
and the applications made a week before and during their
appearance.
Some patients will tolerate much more electricity than will
others. Idiosyncrasy should always be noted, and the strength
and duration of the current regulated accordingly.
THE APPLICATION OF THE FRANKLINIC CURRENT.
The franklinic current may be administered in various ways.
The most common method is as follows: The patient is placed
upon an insulated platform and is connected with the ball sur-
mounting one of the Leyden jars by means of a conducting cord.
The other pole is connected with a ball electrode having an
insulated handle. After the current is created by revolving the
plates, the electrode is applied through the clothing to the
painful parts and up and down the spine.
In the indirect method, the second conducting cord, instead
of being attached to the ball electrode, is placed on the floor
near the platform, for the purpose of creating a certain degree
of induction. The electrodes passing through the balls which
surmount the Leyden jars are drawn beyond sparking distance.
After the current is created sparks are drawn from the patient
by a suitable ball or sponge electrode.
The "electric bath" or "static breeze" is administered, with
or without the insulated stool, by using a point electrode or a
static crown instead of the roller or ball electrode. The patient
is fanned by a gentle current of electrified air, which produces a
ELECTRICITY IN GYNECOLOGY.
159
delightfully cooling sensation, and which is exceedingly useful
in dealing with neurasthenic cases.
The faradic current may be created by the static machine in
the following way: The conducting cords are inserted in the
two sockets on the front edge of the base, the free ends being
attached to the metal electrodes. The switch is opened and the
sliding electrodes closed. The discharge is then regulated by
separating the sliding electrodes. With a separation of one-
sixteenth of an inch a very smooth faradic current is obtained;
a separation of one-quarter of an inch, on a large machine, will
afford a current quite as powerful as the strongest nerves can
endure.
Let it be remembered that while electricity, in many instances,
may be the chief therapeutic agent, it is rarely the only one to
be used. It must be supplemented by other treatment, both
constitutional and local. Again, it must be used patiently, per-
sistently, and with discrimination. It is impossible to cure
symptoms like amenorrhoea and dysmenorrhoea, when due to
constitutional causes, by local electrization. Unless the cases
are properly selected failure will be inevitable.
I purposely omit giving the technique of electro-puncture as
practised by Apostoli, Keath, Engelmann and others in the
treatment of hyperplasia and fibroma uteri, for the reason that I
consider this treatment unsurgical and unscientific. Candor
compels me to state that this somewhat dogmatic conclusion is
not based upon personal experience, but rather upon deductions
drawn from principles which seem to me clearly defined in deal-
ing with surgical conditions, and upon observation. Patients
have come to me who have been subjected to almost insufferable
agony by the method of Apostoli without the least benefit, and
not a few cases have come to my knowledge in which the out-
come has been fatal. In the light of surgical data furnished by
Bantock, Thornton, Tait, Leopold and others, the results do not
seem to justify the means.
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A TEXT-BOOK OF GYNECOLOGY.
APPLICATION.
AMENORRHEA.
The cases of amenorrhea in which electricity is useful must
be selected with discrimination. In all instances the benefit to
be derived from the use of the agent will depend upon the cause
of the amenorrhea. In other words, amenorrhea must be looked
upon as a symptom and not a disease, and treated accordingly.
It may be either partial or absolute. When absolute the prog-
nosis will in no small degree depend upon the presence or
absence of the molimina.
Obviously it would be improper to make an effort to restore
the menstrual discharge by the aid of electricity when due to
the presence of diseases like tuberculosis, chlorosis, Bright's
disease, or anemia. However, there yet remains a class of cases
constantly presenting themselves for treatment in which men-
struation is absent or scant, because of deficient development
of the sexual organs, or because of suppression due to nervous
shock or change of residence, in which electricity is one of the
most useful therapeutic agents.
Girls who have never menstruated may have the function
delayed, because of an entire absence of the uterus and ovaries.
If a physical examination reveals this fact there will be but
little use persevering in any kind of treatment, either local or
general. On the other hand, if the development of these organs
is rudimentary, and the symptoms of menstruation, except the
flow, recur at regular intervals, the prospect of thus stimulating
the undersized organs to perform their function is more encour-
aging.
There is still a further class of cases in which, according to
Grandin, the application of electricity is most satisfactory. The
amenorrhea in these cases is due to deficient nerve tone or
force, and is typically "atonic" in character. This form of
amenorrhea may be either primary or secondary, i. e., occurring
in girls who have never menstruated, or in women who have
menstruated, but from some cause, evidently not constitutional,
the flow has gradually or suddenly ceased. In both instances
ELECTRICITY IN GYNECOLOGY.
161
the normal stimulus seems to be absent, and the woman is ill
because she does not menstruate. Sometimes the discharge
seems to go toward the elaboration of adipose, and as a conse-
quence she becomes corpulent concomitantly with the suppres-
sion of the menses. At any rate if a patient thus affected can
be made to menstruate, or if she is menstruating but scantily
the discharge can be increased, she will be made well.
The cases, then, in which electricity is most likely to prove
useful may be enumerated as follows: First, where there is
imperfect development of the sexual organs with molimina
recurring at regular intervals. Second, where the suppression
is the result of some cause which has been removed and menstru-
ation is not restored because of the lack of what we call, for
the want of a better name, sufficient "nerve tone."
Imperfect development, malnutrition, and atony are the path-
ological factors which are to be dealt with in the types of cases
in the foregoing classification. The symptoms are variable as
regards both intensity and character. In almost all instances,
however, nervous depression is marked and hysterical manifes-
tations frequently occur. Stimulation is, therefore, the object
to be attained, and it is best attained by combined faradization
and galvanization.
The method of application will necessarily depend upon
circumstances. Rockwell emphasizes the necessity of general
faradization in all cases where malnutrition is marked, and
central galvanization in patients hysterically inclined, or victims
of insomnia. I have derived in these cases more good from gen-
eral franklinization. Undoubtedly, the general use of electricity
can often be advantageously combined with the local use of the
agent in any of its forms; but in the cases under consideration
local mechanical effects are required rather than general, hence
local faradization is oftener indicated. This theory is in perfect
harmony with other forms of treatment known to be useful.
The introduction of the sound, the presence of a stem pessary
within the uterine cavity and the insertion of tents have long
been popular methods of stimulating the uterus in a purely me-
chanical way, for the purpose of precipitating the menstrual flow.
There are instances, however, where the local nutrition is at
II
162
A TEXT-BOOK OF GYNECOLOGY.
fault, and something more than mere mechanical stimulation is
necessary. Patients thus affected are often robust and of full
habit, and the application of faradism can be advantageously
combined with galvanism. Again in those instances where the
uterus and its appendages are imperfectly developed, both forms
of electrization are called for.
In young, unmarried girls the indirect method should be
resorted to before direct application is made, though in all
instances the direct method is the most useful and should be
used, if necessary, before the treatment is abandoned. In the
indirect method one pole is placed over the sacrum and the other
over the lower part of the abdomen.
When direct application is made, one pole is applied internally
either through the vagina or the uterine cavity. Suitable elec-
trodes are used for the internal pole. The external pole is
placed over the lower abdominal region.
If the faradic current is applied, it matters but little which
pole is used internally. Inasmuch as the negative is slightly
more irritating than the positive, the chances are that the results
will be more decided if this be made the internal one. When
the galvanic current is used, Rockwell, acting upon the theory
that the positive exerts a more marked influence on unstriped
muscular fibers, prefers it as the internal one. However, most
authorities are agreed that the negative, because of its hemor-
rhagic tendencies, should be made the internal one, unless seda-
tion is required. Care must be taken not to use a current
strong enough to produce caustic effects when the negative pole
is inserted into the uterus.
When the amenorrhea is absolute, the best time to make the
applications is just before and during the molimina, for at this
time nature is making an effort to perform a function which is
held in abeyance. In no instance is entire reliance to be placed
upon electricity, for other local measures, as well as constitu-
tional ones, should be combined with its use.
DYSMENORRHEA.
Dysmenorrhea, like amenorrhea, is only a symptom, and may
be due to one or more of several causes. The various lesions
ELECTRICITY IN GYNECOLOGY.
163
(6
giving rise to painful menstruation are considered under the
several affections of which it is a symptom. There yet remains
a type of dysmenorrhea associated with that condition of the
system which is designated under the head of amenorrhea as
depressed nervous tone." There sometimes exists a condition
of the uterus in which the organ, so far as can be ascertained
by physical exploration, is perfectly healthy in every particular
except that it is hyperesthetic. From some cause the uterus.
is "irritable," and as a result the patient is a victim of dys-
menorrhea. Such a patient is usually of a neuralgic tempera-
ment, the symptoms of neuralgia presenting themselves upon
the slightest exposure.
It is this form of the complaint in which electricity is preëm-
inently indicated. There is an entire absence of local disease,
and the one symptom to be overcome may be defined by the
term "hyperesthesia." Galvanism is, therefore, the most appli-
cable in the vast majority of cases.
The positive pole, being the sedative one, should be used inter-
nally when the direct method is resorted to. Occasionally, and
Rockwell particularly emphasizes this point, when the dysmen-
orrhea is associated with amenorrhea, and especially if there is
a possibility of the difficulty being due to pressure by exudates.
upon nerve filaments, the negative pole should be the direct
one.
Dysmenorrhea may occur when the uterus is imperfectly
developed, or when its diminished size is due to superinvolution.
In instances of this kind stimulation as well as sedation is called
for, and to cover this indication the faradic current must be
utilized. In other words, we should direct our treatment to the
undersized uterus. The necessity of so doing is referred to at
this time as explanatory to the appended schema.
In virgins, the abdomino-lumbar method may be tried before
the direct is resorted to. However, in no instance should the
treatment be abandoned as useless until the direct method has
been faithfully persevered in. The application should be made
at least twice a week during the entire intermenstrual period,
and if possible every day during the week preceding the expected
flow.
Let it be remembered that in any form of dysmenorrhea
164
A TEXT-BOOK OF GYNECOLOGY.
electricity is but an adjunct, though a very important one, to
other methods of treatment.
SUBINVOLUTION.
By subinvolution is meant an abnormal condition of the
uterus, the result of parturition, in which the organ is at first
large, succulent, and congested, this condition passing in due
time into induration and hyperplasia.
The first stage is known as acute subinvolution, and the
symptoms which are to serve as guides in the application of
electricity are hypertrophy and concomitant hypersecretion. The
second stage is characterized by condensation of tissue with
atrophy, constituting that condition ordinarily defined as areolar
hyperplasia. The indications for the use of electricity are very
different in the two stages. In the first the object to be attained
is stimulation and contraction; in the second, absorption of
fibrous tissue and improved nutrition. Other methods of stimu-
lating the uterus and causing it to empty itself of blood are the
hot douche, intra-uterine applications, and the glycerin tampon.
Electricity cannot supplant these several methods and should be
considered simply as a supplement to them. In acute subinvo-
lution the faradic current should be used for a few moments
every day or every other day, followed by the customary
glycerin or boro-glycerid tampon. If any inflammatory symp-
toms exist the greatest care must be observed, particularly
if applied by means of an intra-uterine electrode. By placing
an intra-vaginal electrode in direct contact with the cervix with
the external pole over the abdomen, the current is made to
act upon both the uterus, and the vagina. This is desirable,
for in most instances subinvolution of the uterus is associated
with subinvolution of the vagina. In chronic subinvolution or
areolar hyperplasia, the negative pole of the galvanic current
must be used direct.
SuperInvoluTION AND ATROPHY.
These two conditions are the opposite of subinvolution, yet
experience has demonstrated that in all three electricity is a
valuable therapeutic agent. Rockwell observes that a still more
ELECTRICITY IN GYNECOLOGY.
165
paradoxical feature of electricity is its power to relieve symp-
toms of the most variable character, and its diametrically opposite
action upon normal and abnormal tissue. In proof of this he
cites the fact that it relieves both hyperesthesia and anesthesia ;
that in one instance it will excite torpid excretory processes.
and in another it will restrain this function when too active;
and that while it will surprisingly develop normal tissue it
will often readily reduce morbid growths. This seemingly
paradoxical action is inexplicable to one unfamiliar with the
law, similia.
The object to be attained in superinvolution and atrophy is
stimulation and improved nutrition; this is best accomplished
by alternate faradization and galvanization. It must be admitted,
however, that in superinvolution the results obtained by any
method of treatment are not encouraging. Dr. Fordyce Barker
is of the opinion that the prognosis depends upon the activity
of ovulation. This is in keeping with what has already been
said regarding the prognostic value of the molimina in amenor-
rhea, for the molimina are in most instances undoubtedly due to
ovulation. Dr. Barker gives as further symptoms of ovulation
without menstruation pain and a sense of dragging in the pelvis,
nausea and vomiting, intense headache with flushing of the face
and congestion of the eyes. To this list Dr. Rockwell adds
intense melancholia. So long as these symptoms are present,
and in the absence of more effectual methods, we are justified
in persevering with electricity.
Grandin recommends the application of faradism just before
and during the molimina, using utero-abdominal galvanization
during the intervals. Inasmuch as amenorrhea is usually asso-
ciated with an undersized uterus, the negative pole should be
used direct in order to utilize its hemorrhagic effects.
OVARALGIA.
Neuralgic pains having their origin in or near the region of
the ovaries, with an entire absence of appreciable lesion, consti-
tute that condition known as ovaralgia. As in all neuralgic
affections, the symptoms are chimerical and changeable. Hyper-
esthesia and pain are the ones to be overcome, but in certain
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A TEXT-BOOK OF GYNECOLOGY.
cases faradization is more useful than galvanization. Rockwell,
guided by his extensive experience in the treatment of external
neuralgias, deduces his indications from the effects of pressure:
If pressure relieves, faradism is the preferable form; if pressure
intensifies, galvanism affords more speedy relief. Engelmann,
on the other hand, bases his indications upon the duration of
the difficulty, using the high tension faradic current in acute, and
the galvanic current in chronic cases.
CHRONIC OVARITIS.
There is a variety of chronic ovaritis, characterized by con-
gestion and enlargement of the organ without adhesions, in
which electricity in the form of galvanism is the remedy par
excellence. The congestion and irritation may result from many
causes, but the most common one is sexual irregularity in some
form. There is pain in one or both ovarian regions, which is
worse before and during each menstrual period, and is aggra-
vated by walking. The tendency of modern gynecology is to
remove an ovary thus affected with but little ceremony.
I am
confident that the intelligent use of galvanism would make
many such operations unnecessary.
The hyperesthesia is best overcome by using the positive
pole of the galvanic current direct. A vaginal electrode placed
as close to the enlarged organ as possible, with the negative
pole over the tender external area, is the most satisfactory way
of administering it. If the indirect method is the one employed,
the positive pole should be placed over the ovary and the
negative over the sacrum. I do not think that a current of
greater intensity than twenty-five milliampères is ever neces-
sary. The séances should be repeated at least twice or three
times a week.
CHRONIC PELVIC INFLAMMATION.
Under this head is included inflammation of any of the pelvic
organs, but particularly the uterus and its annexa, together with
their investing cellular tissue and the peritoneum. The pathology
represents congestion and exudation, which, in turn, give rise
to pain because of pressure, and to innumerable reflex symp-
ELECTRICITY IN GYNECOLOGY.
167
toms. If such an exudation can be absorbed, and the pressure
resulting therefrom relieved, the patient is made well. Even
by combining all of the curative measures at our command, viz.,
the hot douche, the medicated tampon, the indicated remedy,
and electricity, we shall often fail in accomplishing this. I
nevertheless contend, that unless it is clearly evident pus has
formed as a sequela of the inflammation, or unless other existing
symptoms make delay hazardous, it is our duty to exhaust
all reasonably safe methods before opening the abdomen. In
the light of present data electricity promises much, and unless
electro-puncture is resorted to, of which I do not approve, is
perfectly free from danger.
In almost all cases of chronic pelvic inflammation there is
both local and general distress and, consequently, in the appli-
cation of electricity three prominent indications are to be met,
viz., sedation, absorption, and the relief of local congestion.
When the local tenderness is very great, and particularly if
menorrhagia is a prominent symptom, as it often is, the positive
pole is the preferable one to use direct. After the local ten-
derness and the hemorrhage have in a measure been controlled
the negative pole should be used direct, because of its destructive
tendencies. Intra-uterine applications must be made with much
care, and intolerance of the uterus watched for. The applica-
tions should be used from two to three times a week, the
intensity of the current being governed, within certain limits,
by the susceptibilities of the patient.
UTERINE DISPLACEMENTS.
Uterine displacements are not infrequently associated with,
or the result of, those pathological changes which have already
been considered in this chapter. When due to any of the
causes enumerated the usefulness of electricity will depend upon
the curability of the subinvolution, the absorption of adhesions,
or the restitution of a relaxed pelvic floor. The kind of
electricity and the method of application will, in such instances,
necessarily depend upon the special lesion or lesions respon-
sible for the displacement. There yet remains a certain number
of cases of ante- or retro-flexion due to deficient muscular tone
168
A TEXT-BOOK OF GYNECOLOGY.
in the region of the internal os, or to imperfect development.
If the weak point in the uterus which is responsible for the dis-
placement can be restored to a normal condition by the use of
electricity, it is certainly more than has yet been accomplished
with any other method of treatment.
It is, however, admitted by Rockwell, who is an enthusiastic
advocate of the agent in this field, that the results have not
equaled the promises made by Tripier and some other specialists.
Its usefulness probably depends upon the hyperemia and the con-
traction of involuntary muscular fibers produced by the current.
If this theory is correct it is desirable to localize its action as
much as possible. To accomplish this the indirect pole should be
placed in the rectum or in the bladder, depending upon the direc-
tion of the displacement. The other electrode is introduced into
the uterus. Faradization is called for in the majority of cases,
but if local nutrition is much involved an occasional application
of galvanism will hasten the cure.
ENDOMETRITIS.
Corporeal endometritis is usually associated with more or
less metritis proper or with subinvolution, and the treatment is
conducted upon the principles recommended for these affections.
In cervical endometritis the usefulness of galvanism can
hardly be over-estimated. Positive cauterization of the cervical
endometrium will very often hasten the cure most surprisingly
when the ordinary resources fail. The applications should be
made not oftener than once a week and supplemented by the
ordinary treatment for that condition. I use for the purpose
Martin's platinum electrode and a current of not less than fifty
milliampères. If there is much hypertrophy of tissue negative
cauterization is preferable to positive.
ELECTRICITY IN GYNECOLOGY.
molimina (prognostic);
NOSOLOGY.
AMENORRHEA.
PATHOLOGY.
SYMPTOMS.
INDICATIONS.
TREATMENT.
Imperfect development Presence or absence of Stimulation and improved Faradization.-General or local. (Rockwell.)
and malnutrition;
nutrition.
Atony.
Nervous depression.
Galvanization.-Central or local, negative
pole direct.
Franklinization.-General.
DYSMENORRHEA.
Depressed nervous tone. Hyperesthesia; Neural
Sedation.
Occasional
Sedation.-Galvanization, with positive pole
gia; Absence of local
disease.
stimulation.
direct.
Stimulation.-Faradization, direct or indirect.
SUBINVOLUTION.
(ACUTE.)
SUBINVOLUTION.
(CHRONIC.)
Congestion.
Hypersecretion.
Hyperplasia.
Deficient secretion;
Hystero-neuroses.
SUPERINVOLUTION. Atrophy.
Amenorrhea.
OVARALGIA.
No tissue change.
Hyperesthesia.
Sedation.
CHRONIC
OVARITIS.
Congestion and inflam- Hyperesthesia.
Sedation.
mation.
CHRONIC PELVIC
INFLAMMATION,
Pelvic congestion ;
Exudation.
Hyperesthesia; Pressure
and reflex symptoms.
Sedation; Absorption and
ENDOMETRITIS.
Congestion and Inflam- Hypersecretion and
mation.
hyperesthesia.
UTERINE DIS-
PLACEMENTS.
Congestion; Inflamma-
tion; Atony.
Depend upon tissue
changes.
Stimulation and contrac-Stimulation.-Direct Faradization.
tion.
Absorption of fibrous tissue
and improved nutrition.
Stimulation and improved
nutrition.
relief of local conges-
tion.
Galvanization.-Positive pole direct.
Galvanization.-Negative pole direct.
Electro-puncture (Apostoli).
Direct Faradization.
Galvanization.-Negative pole direct.
If pressure aggravates-Galvanization.
If pressure ameliorates-Farad. (Rockwell).
Galvanization.-Positive pole direct.
Sedation.-Galvanization, positive pole direct.
Absorption.-Galvan, negative pole direct.
Electro-puncture (Apostoli).
Sedation and relief of Galvanization (positive or negative pole di
congestion.
Depend upon tissue
changes.
Faradization.
[rect).
Congestion.-Galvanization and Faradization
(positive pole direct).
Inflammation.-Galvan. (positive pole direct).
Atony.-Faradization.
169
CHAPTER XII.
ANTISEPSIS IN GYNECOLOGY.
With few notable exceptions all modern surgeons and gyne-
cologists acknowledge the advantages of antisepsis. Those who
do not, admit at least the utility and desirability of asepsis.
There are but few even among the most ardent advocates of
antisepsis who would resort to antiseptics if they thought perfect
asepsis were possible without the use of germ destroying agents.
There is no question that the indiscriminate use of antiseptics in
the past has been attended with harm. This is especially true
as regards the spray. And, too, it must be admitted that we
are yet in ignorance regarding much that pertains to the field of
bacteriology-a science as yet in its infancy. We cannot at the
present time determine with absolute certainty whether, in a
given case, the existing germs are the cause or the product of
morbid processes. Personally, I am a believer in the so-called
germ theory of disease. It affords to my mind the most rational
explanation yet put forth of the transmission of many diseases.
However, in a practical treatise of the nature of this work, an
extended argument for the purpose of sustaining or disproving
this theory would be inappropriate. I nevertheless desire to
suggest the following:-
1. It is altogether probable that more perfect asepsis can be
obtained by the use of antiseptics. I think that even the
opponents of antisepsis will admit this; and unless antiseptics.
are harmful, it seems to me wiser to be on the safe side and
resort to their use.
2. Surgeons have now learned how and where to use the germ-
destroying agents so as to avoid the evil effects which attended
their early employment. The weakest solutions known to pos-
sess germicidal properties have supplanted the stronger ones,
and even the weaker solutions are not permitted to enter the
170
ANTISEPSIS IN GYNECOLOGY.
171
peritoneal cavity. Again, no antiseptic solution is left in any
natural or artificial cavity of the body to be absorbed. If used
within the uterus, its ready exit is assured either through a
reflux catheter, or through a cervical canal thoroughly patulous;
or if used to wash out a pelvic abscess, a drainage tube is intro-
duced through which the excess of fluid can escape.
In experimenting with antisepsis I have passed through three
stages. When the so-called antiseptic craze first swept over the
country I was fresh from college, and had hardly seen a wound
of any kind heal by first intention. I was delighted with the
early experiments made with carbolic acid and bichlorid of
mercury. Unfortunately I soon met with several cases of car-
bolic and mercuric poisoning, which led to my discarding for
some years these agents entirely. I then studied antisepsis
under some of the best-known Eastern specialists, and came to
the conclusion that the accidents attending their use in my hands
were largely due to faulty technique of application. During the
first seven years of my service in the University of Michigan,
I was compelled to do all of my hospital work in a building
notoriously insanitary. As soon as I began to practise anti-
sepsis in a fairly intelligent way my results were infinitely
better; yet, in spite of the precautions taken, I had to do every
now and then with suppurating wounds. Later I studied the
technique of antisepsis in many of the European hospitals. Sir
Joseph Lister's methods, as practised in King's College Hospital,
disappointed me. I never have seen more untidy operating than
witnessed in the clinic of the "father of antisepsis." This
surgeon washes his wounds with a small quantity of bichlorid
water, which he uses until it becomes absolutely thick with
blood; yet, I am informed, his results are good. In nearly all
of the London hospitals visited by me during the year of 1889
antisepsis was practised in this same haphazard manner. With
the Continental surgeons, on the other hand, antisepsis has be-
come almost a religion. As practised by such men as Leopold
of Dresden, and Martin of Berlin, it means a great deal more
than was comprehended by me before seeing these men operate.
I now endeavor to carry out their methods as nearly as possible
and am more than satisfied with the results obtained. Pus in
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A TEXT-BOOK OF GYNECOLOGY.
the healing of wounds is almost unknown to me. When suppu-
ration does occur, I can usually trace the cause to some avoid-
able source of infection-improperly prepared ligatures oftener
than anything else.
It is true that the success of men like Tait, Bantock, and a few
others who ignore antiseptics, forces itself upon us. I have seen
both of these men operate, Dr. Bantock many times. Tait does
not even practise asepsis. I have seen him remove his finger
from the vagina and thrust it into the abdominal cavity without
even the formality of wiping it off. Bantock is as neat an opera-
tor as ever picked up a knife. Everything about him is clean.
In short, he practises asepsis. The great success of Tait can
readily be accounted for by the genius of the man. He will
make an abdominal section while the ordinary operator is rolling
up his sleeves. His patients suffer the minimum of shock, for
the intestines are hardly exposed. Both of these operators use
drainage very much oftener than do the men who practise anti-
sepsis.
My own experience and observation, therefore, force upon me
the advantages of antisepsis. I should like to discard the prac-
tice if I could conscientiously do so, for, rigidly carried out, it
means an endless amount of work and care. While such men
as Tait and Bantock may dispense with antiseptics, it seems
to me that, with few exceptions, the best results have been
obtained by the surgeons who use them.
The application of antisepsis in the practice of gynecology
will be dealt with under the following heads:-
I. The agents employed.
2. The operator and assistants.
3. The patient.
4. The operating room.
5. The operation.
(a). The preparation and care of instruments;
(b). The preparation and care of ligatures, sponges, and
drainage tubes;
(c). The use of the irrigator;
(d). The dressings employed.
6. The after treatment.
ANTISEPSIS IN GYNECOLOGY.
173
1. The Agents Employed.-For making antiseptic solutions.
I use almost exclusively corrosive sublimate and carbolic acid.
These can always be obtained, are inexpensive, and, above all,
are probably the most trustworthy agents yet used. Creolin
and beta-naphthol are highly recommended by some operators.
Permanganate of potash is also used quite extensively for the
purpose of disinfecting the hands. On the whole, it is better for
the surgeon to adhere to those agents which he knows to be
efficacious, and which he has learned to use intelligently.
2. The Operator and Assistants.-First of all, the operator,
especially if doing abdominal surgery, should never come in
contact with contagious or infectious diseases of any kind; nor
should he or any of his assistants come from the dead room to
the operating amphitheatre. Frequent washing of the entire
body, including the head and beard, should be practised. In
the event of contact with any of the contagious or infectious
diseases, corrosive sublimate (1:2000) should be used to cleanse
the person. The clothing should be absolutely free from infec-
tion of any kind, and, during the operation, protected with an
operating gown and apron extending from the neck to the feet.
The sleeves should be rolled above the elbows, and the nails
scrupulously cleaned. The hands and arms are next thoroughly
washed with soap and water, and then for five minutes in a
I: 1000 bichlorid solution.* Kelly of Baltimore, follows this
by immersing the hands in a solution of permanganate of potash
(4: 1000), after which they are washed in a concentrated solution
of oxalic acid. This is an extreme measure, and one which I
do not resort to unless there is clinging to the hands an odor
resulting from contact with fetid discharge or substance—can-
cerous discharge, fecal matter, etc. The operator should refrain
from operating if he has a suppurating wound of any kind on
his hands.
3. The Patient.-The necessary preparation of the patient
will depend somewhat upon the nature of the operation. For
the ordinary operations upon and through the genital tract the
* I have found Johnston's Ethereal Antiseptic Soap, manufactured by Parke, Davis
& Co., exceedingly useful for this purpose.
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A TEXT-BOOK OF GYNECOLOGY.
patient should take a bath the night preceding, or the morning
of the operation. The bowels should be emptied by an enema
not later than two hours before the anesthetic is given (if the
enema is administered later than this water is retained and will
be expelled during the operation). In surgical work of the
rectum it is a good plan to follow the enema with a saturated
solution of boracic acid (30: 1000). The patient should have the
vagina washed with a large hot bichlorid douche (1: 3000) before
being placed upon the table. It is also well to have the external
genitalia scrubbed with soap and water and an antiseptic pad
placed over them.
After the patient is anesthetized the mons veneris and external
genitalia are again washed with soap and water, shaved, and
finally douched with a 1:2000 bichlorid solution. Next the
vagina, by the aid of the fingers, is thoroughly washed with the
same solution. If the operation is upon the cervix or within
the uterine cavity I first remove as much of the discharge as is
possible with absorbent cotton, and then pass into the cervix
an applicator dipped in impure carbolic acid.
In abdominal cases the bowels should be emptied the day
before the operation with a cathartic, and the morning of the
operation with an enema. The skin should be gotten in good
shape by frequent bathing-the last bath being a 1:2000 bi-
chlorid solution. A compress wrung from a 1: 1000 bichlorid
solution is applied to the lower abdominal and genital regions
for twenty-four hours previously to the operation. The vagina
is prepared with the same care as in operations confined to this
canal. After the last douche it is packed with iodoform gauze,
which is to be left in until the patient is anesthetized. The
pubes should be shaved on the day preceding the operation.
When everything is in readiness to operate, the compress and
tampon are removed, the field of operation again washed with
soap and water, and finally with a 1:1000 bichlorid solution.
Especial care is to be observed in cleaning the umbilicus, in
order to dislodge all hidden accumulations. Next, sterilized
towels are wetted in a 1:2000 bichlorid solution and placed in
such a way as to cover the entire surface of the abdomen
(except the immediate site of the incision), the genital region,
ANTISEPSIS IN GYNECOLOGY.
175
and the upper thighs. All instruments, ligatures, etc., are thus
prevented from coming in contact with any portion of the
integument.
4. The Operating Room.-In the construction of hospitals
the operating room should be as far removed as it can be from
the general wards, or from other possible sources of infection.
It should be so constructed as to be easily cleaned, and there
should be no unnecessary angles or woodwork upon which
dust or germs can lodge. The furniture should be scanty and
exclusively of metal or glass. A sky-light, especially in abdom-
inal work, is most desirable. Antiseptics of variable strength,
and sterilized water, should be conveniently at hand.
In operative work outside of the hospital all mattings, cur-
tains, tapestry, and unnecessary furniture should be removed.
A room should be selected possessing a good light-preferably
with a southern exposure. Inquiry should be made as to whether
the room has been recently occupied by contagious or infectious
cases. If an abdominal section is to be made old paper should
be removed, the walls washed with a 50: 1000 carbolic solution,
and followed by sulphur disinfection. The room ought to be
gotten ready at least forty-eight hours before the operation.
The Operation.-Various methods having for their object
the disinfection of instruments are in vogue. I rely almost entirely
upon boiling in sterilized water. The antiseptic agents are
so injurious to all metal instruments that I have discarded
them for this purpose. Heat maintained at a proper temper-
ature and for a sufficient length of time is, to my mind, the best
of all antiseptics. In the first place I obtain instruments of the
simplest construction, which can be taken apart and thoroughly
cleaned. The handles should be of metal so that the boiling
will not damage them. After an operation all instruments are
scrupulously cleaned, boiled, and dried. Before being used
again they are boiled for twenty minutes, removed from the
boiling water and immersed in sterilized water contained in
operating trays. This method possesses all the elements of sim-
plicity and can be applied under all circumstances. In hospital
work a sterilizing oven may be substituted for the boiling
process. All towels used about the operation should be
•
176
A TEXT-BOOK OF GYNECOLOGY.
thoroughly sterilized by being subjected either to dry heat or
to boiling.
The ligatures most generally used are silk, silkworm gut, and
silver wire. The flat plaited silk is preferable to the twisted. It
comes in six sizes and should be boiled for an hour in a 50:1000
carbolic solution. It should be kept in the same solution in
some convenient ligature holder admitting of its withdrawal
without contamination. Silkworm gut may be prepared and
kept in the same way.
Kocher's method of preparing catgut, as given by Gerster,* is
as follows:
"Immerse catgut for twenty-four hours in good oil of juniper (ol. juniperi baccarum,
oil of the berry, not the oil gained from the wood); transfer into and preserve in
absolute alcohol until used. Alcohol keeps catgut hard and firm, yet flexible.
Carbolic acid or corrosive sublimate will make it brittle and weak. When it is
desirable to prevent too early absorption, as, for instance, in intestinal sutures, a
hardening process should be added to the disinfection. The catgut should be washed
in alcohol, then placed in a quart of a five per cent. solution of carbolic acid con-
taining thirty grains of bichromate of potash. Forty-eight hours immersion will
produce catgut that will resist the action of living tissue for a week or longer. Large-
sized catgut needs a longer immersion."
I am using catgut more and more in plastic work as time
goes on.
If properly prepared and perfectly aseptic it is one
of the best of ligatures, possessing the great advantage of being
absorbed. It is the one suture, therefore, which can be buried
in the tissues. Unfortunately it is easily contaminated and its
use requires great care.
The only preparation required in using silver wire is heat
sterilization.
I have for some years resorted to Borham's method of cleaning
sponges. I quote from J. Greig Smith †:
"The sponges are first repeatedly washed in water for the purpose of removing
all sand and dirt. This requires several days' time. They are next soaked for three
or four minutes in a one per cent. solution of potassium permanganate. The per-
manganate is then washed out by repeated squeezings in fresh water. Next, they are
placed in a solution of sodium hyposulphite, of the strength of half a pound of the
salt to the gallon of water, to which an ounce of oxalic acid has been added. Finally,
they are washed in cold water, dipped in carbolic solution, and dried.”
* “ Aseptic and Antiseptic Surgery."
† Abdominal Surgery, 1887, p. 60.
ANTISEPSIS IN GYNECOLOGY.
177
After this preparation they should be kept in a clean paper
bag or a closed glass jar until used.
I prefer to purchase inexpensive sponges and use them but
once. It is entirely possible, however, unless they have come in
contact with septic matter, to clean them after being used so as
to make them again perfectly aseptic. They should be first
washed in plain water, so as to remove as much of the blood and
filth as possible. They are next placed in the soda solution,
which will dissolve the blood and fibrin. This should be changed
several times, and the sponges should be repeatedly washed and
squeezed in it. Finally, they are cleansed in pure water, "dipped
in carbolic solution, squeezed and dried, and kept in a dry place
till further use." After septic operations, it is best to destroy
them.
Owing to the danger of sponge contamination some operators
have abandoned them entirely, substituting for them compress
sponges. These are prepared as follows: "A piece of gauze is
folded so as to form a square of thirty centimeters (10: 12 inches),
composed of eight thicknesses of cloth. These compresses
are fastened at several points along each border. Then they
are boiled for two hours or less, either in a carbolic solution
(50: 1000), or in bichlorid (1:1000). Finally, they are pre-
served in a fresh solution of the same, which should be changed
every week. Before using they should be carefully washed in
sterilized water and wrung as dry as possible. They then con-
stitute a powerful absorbing agent, which can be quickly given
any form or dimension, can be wrapped around the finger in
penetrating into cavities or interstices, when exposing the intes-
tines, which, in a word, offers advantages much superior to
those of sponges."-Pozzi.
I have often used the compress sponges in abdominal work
instead of the large flat sponges, which are very expensive.
When smaller sponges will answer the purpose, I prefer them to
the compresses.
Rubber drainage tubes are not often required in gynecological
surgery. Soft, pliable rubber tubing, of black material and of
proper size, should be selected. This is cut into suitable lengths,
which are placed in a wide-mouthed bottle and immersed in a
12
178
A TEXT-BOOK OF GYNECOLOGY.
<
five per cent. carbolic solution. The solution should be renewed
from time to time.
For abdominal drainage, glass tubes are used oftener than any
other form of drainage. The antiseptic solutions do not injure
the glass, and they can be boiled for twenty minutes either in a
five per cent. carbolic solution or a 1: 1000 sublimate solution.
They should be rinsed in sterilized water before being placed
within the peritoneal cavity.
Another form of intra-abdominal drainage which has become
very popular during the last two years is so-called tamponnement
of the peritoneum, first suggested by Mikulicz.* The object of
tamponnement is, primarily, to isolate the portion of the perito-
neum tamponed from the rest of the peritoneal cavity, and,
secondarily, to afford drainage by capillary attraction. Mikulicz
first places at the bottom of the cavity to be tamponed a purse
of iodoform gauze, to the middle of which is attached an anti-
septic silk ligature (Fig. 57). Strips of gauze are now packed
into this purse in such a way as to produce sufficient pressure
to control oozing. The superior ends project from the neck of
the purse at the lower extremity of the abdominal wound. I
have often used gauze packing within the abdominal cavity
without the precaution of first introducing the purse. It is, how-
ever, more difficult and painful to remove one continuous long
strip than several shorter ones.
The tampon may be left within the peritoneal cavity for from
one to five days. In one
In one case I found it necessary to use
nearly four yards of gauze (one yard wide) in order to prevent
immediate death from hemorrhage. It was partly removed on
the third day, but it was not all withdrawn until the end of the
seventh, and was then perfectly sweet. In controlling hemor-
rhage from large oozing surfaces I know of nothing more satis-
factory in abdominal surgery than gauze packing. If deemed
best a glass drainage tube may be introduced into the center of
the tamponnement, though by placing a pad of gauze over the
* The reader is referred to the Annales de Gynécologie et d'Obstetrique, 1890, for
a most exhaustive résumé on the subject of abdominal drainage by Saenger of
Leipzig.

ANTISEPSIS IN GYNECOLOGY.
179
ends projecting from the abdominal cavity capillary drainage is
usually sufficient.
In all operations upon the cervix, vagina, perineum, bladder, or
rectum, and in vaginal hysterectomy, the irrigator is invaluable.
Irrigation can be practised either in the lithotomy or Sims
FIG. 57.
b/
a
PETHAL
TAMPONNEMENT OF THE PERITONEUM.-Pozzi.
a a. Purse of iodoform gauze; b. Silk thread; c c. Strips of gauze.
posture. Until I saw the German operators work I used the
Sims posture for all work upon the cervix and vagina. With
the patient upon her side it is exceedingly difficult, in using
irrigation, to keep from wetting her. I now resort to the
lithotomy position in all operations within the vagina, except
those for vesico-vaginal fistula. By using Frisch's modification
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A TEXT-BOOK OF GYNECOLOGY.
of Simon's specula the irrigating tube can be attached to the
upper blade, at the tip of which is an opening through which
the water can pass. The size of the stream is controlled by a
stop-cock near the attachment of the tube.
Either the bichlorid (1 : 5000) or the carbolic (10:1000) solu
tion may be used for irrigation. The parts are kept constantly
bathed in one of these fluids, thus preventing wound infection
during the operation, and making sponging unnecessary.
using the buried catgut suture irrigation should be constant.
In
Gynecological dressings, outside of abdominal work, are of the
simplest character. After plastic operations in and about the
vagina and perineum it is my practice to sponge the parts dry
and sprinkle iodoform over them. A strip of iodoform or
bichlorid gauze is then packed into the vagina and about the
cervix for the purpose of sustaining the parts should the patient
vomit. This is removed in from five to ten hours. Over the
vulva is placed an antiseptic pad. *
When the wound is closed by the buried catgut suture, it is
recommended by Marcy of Boston, that it be hermetically
sealed with iodoform collodion.
In laparotomy, after the abdomen is closed by whatever
method adopted, the wound is washed with a 1: 2000 sublimate
solution, dried, sprinkled with iodoform, protected with a narrow
strip of sterilized oiled silk, and covered with iodoform or subli-
mate gauze, over which is placed several layers of sterilized
absorbent cotton. The dressings are held in place by a sterilized
* Gauze may be prepared as follows:-
Bichlorid Gauze.-Wide mesh cheese-cloth cut into convenient pieces. Then
soak for twenty four hours in a solution of soda (one pound to twenty yards of gauze,
and sufficient boiling water to cover). Wring; wash in cold water. Then for forty-
eight hours in bichlorid 1: 1000. Wring; dry; fold.
Carbolized Gauze.—A five per cent. carbolic solution is used in place of the
bichlorid.
Iodoform Gauze.-Take
Iodoform,
Glycerin,
Bichlorid sol. (I : 1000),
•
•
D
3 ss
3ss
• qt. j.
In this mixture soak ten yards of bichlorid gauze prepared as above, wring and
then fold.-Mundė.
ANTISEPSIS IN GYNECOLOGY.
181
binder. Should a drainage tube be introduced its mouth is
protected by a sponge wrung from a I: 2000 sublimate solution
surrounded by a sterilized rubber dam.
6. The After Treatment. For much pertaining to the after
treatment the surgeon will have to rely upon the nurse and
general attendants. Consequently, unless he can impress upon
them the importance of antisepsis, all of his precautions will
have been in vain. I know of nothing more exasperating than
a slovenly nurse, one who is not sufficiently intelligent, or, if
she is, will not follow the surgeon's directions. In operating
outside of the hospital it is, therefore, wise to have printed
instructions with which the nurse can jog her memory after the
surgeon's departure.
*
In all plastic operations I permit the patient to urinate spon-
taneously if she can do so. After urination the nurse is
instructed to use a small 1: 3000 cleansing douche of bichlorid.
I have every reason to feel satisfied with this treatment, for
failure in primary union is almost unknown to me. If the
patient cannot urinate naturally the catheter is used, care being
observed to keep the finger over the mouth of the instrument
while it is being withdrawn, so that not even a few drops of
urine will come in contact with the wound. When the catheter
is used no injections are necessary unless there is a contaminat-
ing discharge from the upper genital tract. It is hardly neces-
sary to add that, when the douche is used, each patient should
have a separate nozzle, and this should be frequently cleaned.
Antiseptic precautions cannot be too rigorously carried out in
the use of the catheter. I have discarded absolutely the old
silver female catheter, and very rarely use the rubber instrument.
In their stead I use Kustner's glass catheter made by George
Tiemann & Co. They are inexpensive, sufficiently strong to
insure against breakage, and can be boiled and cleaned repeatedly.
The soft rubber instrument cannot be used with safety more
than six or eight times, and cannot be kept aseptic. The nurse is
instructed to boil the glass instrument each time after its with-
drawal. It is then kept in a carbolized solution until again
* I will not even except lacerations of the perineum closed immediately after labor.
182
A TEXT-BOOK OF GYNECOLOGY.
required, when it is rinsed in water and smeared with carbolized
vaseline before being introduced.* Always before its introduc-
tion the vestibule should be washed with an antiseptic fluid of
some kind. Before observing these somewhat extreme measures
urethral and vesical irritation, and even inflammation, were of
frequent occurrence in my hand. Now I rarely if ever have to
contend with any trouble of the kind.
In laparotomy, where the drainage tube is used, the syringe
for drawing off the fluid should be constantly immersed in a
a 50: 1000 carbolic solution. The sponge over the mouth of
the tube should be frequently changed and care observed not to
leave the opening unprotected any longer than is absolutely
necessary. Of course previously to each dressing the hands of
the attendant should be washed in an antiseptic solution.
ANTISEPSIS IN ORDINARY GYNECOLOGICAL EXAMINATIONS.
In ordinary gynecological examinations the danger of possible
infection should always be borne in mind. There is no ques-
tion that the various specific diseases are frequently conveyed
through unclean instruments. When the uterine cavity is
explored, precaution is especially necessary. The hands should
always be thoroughly cleaned in a carbolic solution before and
after each examination. The bichlorid solution for constant
washing of the hands is too irritating. The examining instru-
ments-specula, probes, tenacula, etc.—ought to be frequently
boiled and kept bright by the use of sapolio. They are to be
kept immersed in a carbolic solution during the examination.
Each time after using they should be washed in boiling water
and again immersed in the carbolic solution. I use the carbolic
solution here because it is impracticable to boil the instruments
after each examination. It will, of course, tarnish them some-
what, but the cost of replating is slight, and a physician has no
right to subject his patient to the slightest danger of infection.
The old-fashioned bi- and tri-valve specula are harbingers of
filth and germs. It was this fact which led me to devise the
* Unless care be observed septic matter may be transmitted through the vaseline.
ANTISEPSIS IN GYNECOLOGY.
183
instrument shown in Fig. 27. The blades can be quickly
separated and the joints gotten at with perfect ease.
It is wise to dip the uterine sound and probe into impure car-
bolic acid before they are inserted. If recently used in a sus-
pected case of gonorrheal endometritis, a still safer procedure
is to heat them over a spirit lamp.
In the application of electricity through the genital tract, the
same care as regards cleanliness must be observed. When the
intra-uterine electrode is used, it should be introduced through
a speculum, so that the vagina and cervix can be first washed
with an antiseptic solution. The electrodes insulated with either
hard or soft rubber cannot be sterilized by heat, so that unusual
precaution is necessary in washing them. In cleaning the spiral
intra-uterine platinum electrode of Martin, a good brush is
necessary in order to dislodge the secretions which find their
way between the wires of the spiral.
CHAPTER XIII.
THE HYSTERO-NEUROSES: HYSTERIA.
DEFINITION.
The term hystero-neuroses, in its restricted sense, implies the
uterine origin of symptoms manifesting themselves in organs
remote from the uterus, without structural change in such
organs, being the direct result of reflex nervous influence
starting from the uterus. By common usage reflex symptoms
of ovarian origin are also defined as hystero-neuroses, although
the term oophoro-neuroses would more correctly indicate their
origin.
If it be true that disorders of the rectum, or of any of the
pelvic organs, produce reflex symptoms-and there is abun-
dance of clinical evidence to show that they do-it is obvious
that the foregoing definition is too restricted. The word
"hysteria" was used by the early writers to define the multi-
tudinous phenomena now classified under that name, because of
the erroneous idea that the womb (úσtépa) moved about to
various parts of the body and so caused the local symptoms.
(Gowers.)* The adjective “hystero" is derived from the same
Greek word, and likewise erroneously suggests the uterine origin
of a class of symptoms to which the term pelvic neuroses would
be more literally correct, and infinitely more scientific. While,
therefore, it is the mission of the gynecologist to treat any
lesion found within the female pelvis, it seems wiser to adhere
to the name (hystero-neuroses) which usage has made popular.
The term hysteria should be restricted to the general neuroses
characterized particularly by psychical as well as secretory, vaso-
*"Plato says that the uterus, being an animal desirous of generation, if unfruitful
for a long time, becomes indignant, and wandering all over the body stops the passages
of the spirits and the respiration, occasioning thus the most extreme anxiety and all
sorts of diseases."—Jenks.
184
THE HYSTERO-NEUROSES: HYSTERIA.
185
motor and reflex derangements. It is probable that hysteria
belongs among the cerebro-spinal affections. It is by no means
limited to the female sex, although it is much more commonly
met with in women than in men. Therefore, according to the
definitions given, hysteria does not necessarily have its origin
in disordered uterine or ovarian function, while the hystero-
neuroses always have. Inasmuch as the pathology of both affec-
tions is too occult and subtle to be perfectly understood in the
present state of neurological science; and inasmuch as hysteria,
as it manifests itself in women, is usually associated with utero-
ovarian disease, a clinical distinction is often impossible, and
indeed, unnecesary. It is only important to remember that in
hysteria there may be actual disease of the nerve centers, while
in the hystero-neuroses no such disease is present. In both,
however, the nervous centers are unduly impressionable, and I
therefore deem it wise to study the two conditions under the
same clinical head. By so doing I shall at least avoid uncertain
and profitless discussion. Neurasthenia or nervous prostration
is likewise frequently associated with the hystero-neuroses.
GENERAL CONSIDERATIONS.
The so-called neuroses are but beginning to receive the
attention which, from their importance, they deserve. Those
of the genital system constitute but a single group of that varied
conglomeration of symptoms which may have their origin in
any organ of the body. Flint has called attention to the cardiac
neuroses, and to Dr. Pratt we owe much for his work in the
rectal reflexes. The nasal and bronchial neuroses, as well as
the ocular, are now receiving due attention. It is well known
that, under favorable conditions, the slightest derangement or
modification of function in a sensitive organ, so slight as to
attract no attention to that organ, may, to use the simile of a
well-known writer, cause distant organs to respond most
violently-as the alarm-gong responds to the tap of a distant
button.
The sympathy existing between the stomach and the brain is
well known, and the one will quickly respond to any disturbance
186
A TEXT-BOOK OF GYNECOLOGY.
of the other. It may be impossible to overcome reflex asthma
and so called hay fever without directing attention to the hyper-
trophied posterior nares or the nasal mucous membrane. We
are told by the oculist that certain obscure nervous symptoms
and even epilepsy may be due to errors of refraction. All
gynecologists know that an anal fissure will cause not only
exquisite pain at the seat of the lesion, but may disturb the
whole vaso-motor system, giving rise to the most irregular
distribution of blood in various parts of the body. I myself
have seen an obstinate reflex paraplegia disappear only after
curing a urethral fissure. I cite these well-known clinical facts
simply to show that the genital sphere is only one of many
capable of impressing the organism most profoundly in a
reflex way; and the absolute necessity of studying the organism
as a whole in looking for reflex causes.
Neurologists and gynecologists, unfortunately, do not agree.
as to the importance of the hystero-neuroses. I am confident,
however, that the former are often in error in ignoring pelvic
symptoms as causative factors. Careful observation will, I
believe, demonstrate to the neurologist as well as to the general
practitioner, that uterine disease frequently exists, even though
the ordinary symptoms of such disease are wanting. A thorough
study of all of the neuroses tends to broaden the specialist, no
matter in what department of scientific medicine he may be
engaged, for it leads him into the great domain of anatomy and
physiology.
FORMS OF HYSTERO-NEUROSES.
For convenience of study, the hystero-neuroses may be classi-
fied as-
1. Physiological, giving rise to reflex symptoms owing to increased
functional activity, as during menstruation, pregnancy, and
during puberty and the menopause.
2. Pathological, giving rise to reflex symptoms having their
origin in some pathological change of the female sexual
apparatus. (Engelmann.)
This classification is not strictly correct.
The term physio-
logical neurosis is paradoxical, for, if a function is perfectly
THE HYSTERO-NEUROSES: HYSTERIA.
187
physiological, there should be no disturbance suggesting such a
term. The fact remains, nevertheless, that there are few women
who do not suffer some inconvenience during the several crises.
characterized by physiological congestion, and the classification
at least facilitates understanding.
THE PHYSIOLOGICAL HYSTEro-Neuroses.
(a) The Hystero-Neuroses of Puberty. The function of
menstruation in most instances gives rise to more or less dis-
tress, and to a feeling of uneasiness within the pelvis, which is
still without the domain of actual or discoverable disease. This
is especially so before the function is regularly established. In
a girl whose nervous centers are unduly impressionable, reflex
disturbances are common. Headache, nausea and vomiting,
local spasms, neuralgia, choreic manifestations, and actual hys-
teria, are not infrequent symptoms.
(b) The Hystero-Neuroses of Menstruation.-The nervous
symptoms of menstruation often persist during the entire men-
strual life. The congestion causes an increased nervous excita-
bility, and the neurosis, which may have subsided during the
intermenstrual period, recurs. Here again it is probable that a
pathological condition so insignificant as to cause no trouble
without the super-added menstrual congestion is, in at least the
majority of instances, responsible for the neurosis occurring at
this time. Menstrual neuroses are not limited to the actual
period of the flow, often occurring some days before the san-
guineous discharge takes place, and persisting for several days
after it ceases.
(c) The Climacteric Hystero-Neuroses.-The neuroses
occurring at this period are, in nearly every case, traceable to
pathological lesions. And yet symptoms often occur during
the change of life, as during puberty, which are without the
domain of actual disease. There are few women who complete
this period without suffering more or less from flushes, nervous
irritability, faintness, headache, etc.
(d) The Hystero-Neuroses of Pregnancy.-The uterus
and all of the pelvic organs during the pregnant state are char-
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A TEXT-BOOK OF GYNECOLOGY.
acterized by increased functional activity. Neuroses are
frequently excited by these physiological changes, and often do
not cease until the uterine cavity is evacuated and the conges-
tion terminated. The stomach is usually the first organ involved
in a reflex way, as a result of conception, and so common a
symptom of pregnancy is nausea and vomiting that it constitutes
one of its classical signs. The head, the eyes, the salivary glands,
the thyroid, the bowels-indeed every part, and every function.
of the body may be disturbed as a result of conception.
Let it be remembered that the existence of physiological
neuroses is in perfect harmony with the theory already set forth,*
to the effect that either hyperemia or hyperesthesia of the pelvic
organs is essential for the production of reflex symptoms having
their origin within the pelvis. With the data now in our posses-
sion, we are justified in drawing a line between physiological con-
gestion and hyperemia and pathological. Physiological congestion
may affect the female organism either almost imperceptibly or very
profoundly, depending upon the impressionability of the nervous
system; the same is true of pathological congestion and lesions.
It is probable that the degree of local hyperesthesia is likewise
governed by the state of the nervous system. This explanation
is in perfect accord with clinical evidence, and will account for
the contradictory theories held by different men, equally eminent,
regarding the importance of local lesions as symptom-producing
factors. The gynecologist knows very well that the most serious
or fatal local lesion may run its course without exciting any
reflex symptoms, whereas in another patient, differently con-
stituted, the slightest local rent may make her life miserable.
Types of temperament are equally distinguishable during child-
hood. The eruption of the teeth will occur in one child without
the slightest disturbance, while in another this physiological
process will precipitate the most violent convulsions; or, pre-
putial smegma will cause no nervous irritation whatever in one
instance, while in another its presence may cause convulsions,
and even arrest of development.
* v. Chapter VIII.
THE HYSTERO-NEUROSES: HYSTERIA.
189
DIAGNOSIS.
The most weighty diagnostic evidence in determining the
existence of a neurosis is the absence of structural changes in
the organ or part involved. Unfortunately, even learned and
experienced diagnosticians cannot, for instance, always differen-
tiate between vaso-motor disturbance and slight inflammation,
or between a reflex epilepsy and one due to organic disease of
the nerve-centers. Engelmann has so admirably summarized
the essential diagnostic points that I quote from him in full :—
1. A neurosis is probable, and may be suspected-
*
(a) By the existence of violent symptoms without correspond-
ing pathological changes or febrile reaction.
(b) By the existence of lesions, uterine or ovarian.
(c) By the failure of proper remedies to afford relief.
(d) By the aggravation of symptoms in the affected organ
corresponding to exacerbation of uterine diseases.
2 A neurosis is proved-
(a) If symptoms are not aggravated by causes which are
known to aggravate existing pathological changes in the organ
affected. Thus, the use of indigestible food will not aggravate
a gastric neurosis, whilst the most violent symptoms may appear
in response to a diet which would seem indicated in disease
proper.
(b) If the symptoms are aggravated by causes from which
exacerbation of uterine disease may be suspected.
(c) Improvement of symptoms upon treatment of uterine or
ovarian disease regardless of any interference with the organ in
which the neurosis appears.
(d) By a cessation of symptoms upon improvement or cure
of uterine disease.
It is necessary to eliminate from the category of neuroses
those manifestations of pain due to pressure. Pelvic tumors,
inflammatory exudates, or a pregnant uterus may cause most
persistent and agonizing pain in the lower extremities by imping-
ing upon the nerves within the pelvis. Disordered defecation
* American System of Gynecology, Vol. II, p. 77.
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A TEXT-BOOK OF GYNECOLOGY.
and micturition may likewise result from an increased pressure
exerted by the uterus during menstruation. These are not
reflex symptoms and should not, therefore, be confounded with
the neuroses.
PROGNOSIS.
In considering the prospect of recovery from the hystero-
neuroses and hysteria it is necessary to study the duration of
the symptoms, the nature of the lesion to which they are due,
and the previous neurotic history. The severity of the symptoms
is not a safe criterion upon which to base a prognosis. The
slight psychical disturbances which are permanent and per-
sistent in character are of much more serious import than violent
and transitory symptoms. It must not be forgotten, however,
that ineffaceable traces of psychical weakness are apt to follow
in the train of even slight and temporary attacks of insanity.
With the exception of the neuroses of the eye, nearly if not
all of the reflex symptoms originating within the pelvis disappear
upon removing the cause of such symptoms. Functional
changes of that organ may be, and, unfortunately, are frequently
perpetuated if the local disease persist for any length of time.
So, too, if other organs of the body suffer in a reflex way for
years, there is liable to be a certain trace of weakness left
behind after the more distressing symptoms have vanished.
With the foregoing exceptions the prognosis of the hystero-
neuroses is good. But the persistency of the symptoms after
the cause is removed is most variable, and the practitioner should
be cautious not to promise immediate relief in all instances. I
have many times seen a most distressing headache relieved
almost instantly by correcting a displaced uterus, or by a simple
application to an abraded cervix. I have seen a reflex asthma,
which had followed almost every defecation for years, disappear
upon removing a prolapsed ovary. I have on many occasions
witnessed the disappearance of various types of psychoses, and of
pain in various organs and parts of the body soon after the re-
moval of cicatricial tissue from, and the closure of, cervical rents.
I have frequently seen cold hands and cold feet become warm
almost immediately after divulsing the rectum. Immediate
THE HYSTERO-NEUROSES: HYSTERIA.
191
results of this kind will not infrequently follow operations and
local treatment, but oftener the improvement is gradual and
slow. This is especially true when physical debility has been
induced by depraved nutrition incident to reflex disturbance;
for then reinvigoration depends upon the proper performance
of the digestive function. So, too, time is required if there is
anemia due to excessive uterine hemorrhage, for which the
ovaries are removed or the cervical rent is closed; or if there
is a badly subinvoluted uterus requiring months after oper-
ating before it returns to its normal size. Indeed, it is not uncom-
mon for the patient to feel worse for two or three months after a
serious operation, and her symptoms do not begin to disappear
until the system fully reacts from the shock of the operation.
As soon as the marked irritation of the ganglia implicated
begins to disappear improvement sets in, and often of the most
decided character. What the patient describes as "nervous ten-
sion" vanishes; her expression changes from that of dejection to
one of hopefulness; the dark rings surrounding the eyes disap-
pear, as does the sallowness of the skin. She no longer suffers
from distress in the affected organ or organs, and her nutrition
improves simultaneously with the improvement of digestion and
assimilation. It must not be forgotten, however, that when
psychical symptoms predominate there is always more or less
danger of relapse. This is especially true if the patient is
subjected to ill-directed sympathy bestowed by over-zealous
friends. From this it may be necessary to protect her by an
entire change of environment.
CHAPTER XIV.
THE HYSTERO-NEUROSES: HYSTERIA
(Continued.)
SYMPTOMATOLOGY.
A convenient classification of the hystero-neuroses is the
following:-
1. Disorders of Sensibility.
(a) Hyperesthesia;
(b) Anesthesia.
2. Alterations of Motility.
(a) Clonic and tonic spasms;
(b) Paralyses.
3. Circulatory Disturbances.
(a) Central or cardiac;
(6) Peripheral or vascular.
4. Anomalies of secretion and excretion.
5. Disorders of respiration.
6. Disorders of the gastro-intestinal canal.
7. Disorders of the Skin. (Dermatoses.)
8. Glandular disturbances.
9. Disturbances of the nervous system.
(a) General;
(6) Psychical.
DISORDERS OF SENSIBILITY.
(a) Hyperesthesia.-Hyperesthesia may be either general or
local, but it is rarely if ever absent in some form. There is apt
to be an exaggerated sensible irritability, so that sensory stimuli
increase various kinds of pleasure and aversion; or, if the hyper-
esthesia be greatly exaggerated, stimulation of the senses may
produce pain instead of pleasure.
Increased sensible irritability is often perverted, so that stimuli
which would excite in the well actual disgust become a source
192
THE HYSTERO-NEUROSES: HYSTERIA.
193
of pleasure to the hystero-neurotic; or the highest degree of
discomfort may be produced by agencies which, in the well, give
rise to pleasure. There may also be what Jolly terms a psychical
hyperesthesia, characterized by "exaggerated sensations of de-
sires and repugnance.”
The senses of sight and hearing are often extremely hyperes-
thetic. When the eye is involved patients cannot tolerate a
bright light, and in the worst cases they are compelled to confine
themselves to a darkened room. There may be subjective
phenomena of flashes, sparks, or phantasms, but these symptoms
are oftener associated with hysteria or ecstasy due to other
causes than utero-ovarian disease. Nevertheless, hyperesthesia
is probably present whenever hallucinations of vision occur.
Excitation of the sense of hearing gives rise to greater acute-
ness of this faculty, so that in the worst cases slight noises are
not only distressing but painful. Ringing, blowing, roaring, etc.,
frequently occur as subjective phenomena. From a patient
whose greatest distress was a tinnitus aurium, for which she had
been examined by my colleague, Prof. D. A. MacLachlan, who
found no local ear disease, I removed an incredible amount of
cicatricial tissue from the cervix, which entirely relieved the
tinnitus. Hallucinations of hearing are rarer than visionary
hallucinations, and when present suggest the possibility of
permanent mental aberration.
Perverted smell and taste occur with especial frequency.
Odors which ordinarily are pleasant become repugnant and the
most delicious flavors may excite nothing but disgust. On the
other hand, unpleasant and disagreeable substances which are
repellent to the healthy may be sought for. Cravings for chalk,
dust, coal, and like materials are not uncommon. The acuteness
of smell is sometimes remarkable. One patient of mine could
detect the odor of musk contained in a medium trituration and
carried within a pocket case immediately upon my entering her
chamber. A case is recorded by Amann of a woman who could
distinguish persons by smell.
The sense of touch is rarely exaggerated, though it may be.
The refinement of touch varies greatly in different people who
are in every way healthy. The" muscle reader" possesses such
13
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A TEXT-BOOK OF GYNECOLOGY.
refinement to an extreme degree. If this same exalted sensi-
bility implicates any of the sensory regions, cutaneous hyperes-
thesia of that region is the result. It may be limited to a small
portion of the body or it may be general.
The hyperesthesia often involves the deeper structures, impli-
cating muscles, fascia, and joints. Actual disease is so closely
simulated as to make it oftentimes exceedingly difficult to
determine the spurious from the genuine. The so-called hys-
terical joint is not uncommon, and frequently has its origin
within the pelvis. Mitchell, Brodie, Pajet, and Hilton have
placed on record many such cases. If there has been real
injury to the joint, with hysterical phenomena either preceding
or following such injury, the problem is often exasperatingly
perplexing. With the purely hysterical joint there is pain
without heat or swelling; again, forcible apposition causes much
less pain than superficial pressure, and electrical reaction remains
normal. The knee joint is the one most often affected, and next
to this the hip and wrist. The smaller articulations are rarely
involved.
Hyperesthesia of the scalp is usually associated with an intense
headache. A reflex headache is a common symptom of utero-
ovarian disease. It is aggravated by emotional disturbance, and
is particularly liable to recur at each menstrual period. The
pain is oftener located in the vertex or the occiput, but not
infrequently it partakes of the character of neuralgia, implicating
the occipital, and different branches of the fifth nerve; or there
may be hemicrania, or clavus hystericus. Following these attacks
of headache hyperesthesia of the scalp, or of the underlying
muscles, is often marked.
The genito-urinary system frequently becomes hyperesthetic.
The external genitals, the bladder and urethra, are oftener sensitive
because of actual disease; they may, however, become ex-
quisitely so without any demonstrable cause. That condition
known as hysteralgia is likewise a purely functional disorder
without any textural change in the uterus to account for the pain.
Coccygodynia with hyperesthesia is sometimes purely reflex,
but usually it is the result of structural disease in or about the
bone.
THE HYSTERO-NEUROSES: HYSTERIA.
195
Pain and hyperesthesia of the back may result from over sensi-
tiveness of the vertebral periosteum, from increased muscular
sensibility, or it may be entirely superficial. The most fre-
quent seat of superficial pain along the back is between the
scapulæ, but it often makes its appearance alternately along
different portions of the spinal column; or it may present
simultaneously at different and widely separated points. Fre-
quently the area supplied by the intercostal nerves passing
from the vertebral column at the sensitive point is painful,
giving rise to so-called intercostal neuralgia.
When hyperesthesia affects the region of the vertebral column
in this way it is known as spinal irritation. There is no doubt
that it exists as one of the forms of the hystero-neuroses
and, if so, will disappear on curing the pelvic lesion. The
exact pathological condition of the structures involved is
yet an unsettled point. Valleix* considers the condition one
of the manifestations of hysteria. Inman† ascribes the pain
excited by pressure over the spinous processes to an involve-
ment of the muscular attachments. Erichsen, Hammond, §
and Gowers || believe that the pain radiating from the spine,
when structural lesions are absent, is due to anemia of the
posterior columns of the cord. The explanation last given is
probably the correct one, as it is in harmony with the fact that
spinal irritation oftener occurs in anemic subjects.
It is very important to differentiate between simple spinal irri-
tation and chronic myelitis, meningitis, and congestion.
In myelitis there is often anesthesia instead of hyperesthesia ;
the muscular contractions are frequent and painful, and there is
a sensation as if a tight cord were tied around the body at the
upper limit of the paralysis. (Hammond.) The bladder and
rectum are frequently implicated, and paralysis with atrophy
is sooner or later developed. When paralysis results from
* "Traité des neuralgies, ou affections douloureuses des nerfs," p. 345.
†“On Myalgia: its Nature, Causes, and Treatment,” p. 225.
"On Concussion of the Spine, etc.,” p. 188 et seq.
"Diseases of the Nervous System," 1886, p. 399 et seq.
|| "Diseases of the Nervous System," 1888.
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spinal irritation, which is seldom the case, it is rarely complete,
and there is never atrophy of the muscles involved. Myelitis,
unless arrested, steadily progresses toward a worse condition,
which is not the case with spinal irritation.
In spinal meningitis there is persistent pain in the cord, and
the spinal tenderness is not increased by pressure. Painful
spasms of the muscles of the back is a constant symptom.
sa
In congestion of the cord there is no spinal tenderness, and all
of the symptoms are aggravated by the recumbent posture,
because in this posture the blood gravitates toward the spinal
centers.
Pain over a circumscribed area of the extremities may resemble
very closely a periostitis.
Illustrative Cases.
CASE I.—Neurosis of the Anterior Tibial Region Simulating Periostitis. Cured
by Emmet's Operation.—Mrs. T. L., æt. 28, presented herself at the surgical clinic of
Professor H. L. Obetz during the fall of 1887. Her chief distress, and the only
symptom of which she complained, was a circumscribed tenderness over the anterior
tibial region of the left side. It dated from the birth of her first and only child two
years previously. The pain was constant and persistent, worse during menstruation
and after getting warm in bed. It was unaffected by the weather. She had been
subjected to local blistering and constitutional treatment without avail. There was
nothing of the "hysterical" about her temperament, being exceedingly phlegmatic
and with no trace of psychical disturbance. There were no evidences of heat or
swelling, and the case was referred to me for local examination. I found a badly
lacerated cervix and perineum, which were repaired in the usual way. In two weeks
after the operation the pain in the limb had entirely disappeared, and remained absent
until eighteen months subsequently, when she gave birth to a second child. It then
returned, and an examination revealed a recurrence of the laceration. Up to the
present time she has not submitted to a second operation, and the pain persists.
CASE II-Hysterical Joint of Three Years Duration, Simulating Morbus
Coxarius, Cured by Directing the Treatment to the Pelvis.-Miss E., a bright, intel-
ligent girl, æt. 19, consulted me during the spring of 1890 for what had been diag-
nosed as hip-disease. Three years previously she fell down stairs while at school,
striking upon the buttocks, soon after which she was taken with a severe pain in the
occipital region, which compelled her to leave school. In a short time the left hip
began to pain her, when she took to her bed and never walked up to the time of con-
sulting me, except for a short period while wearing a brace. She had consulted
various physicians of various schools, had submitted to all kinds of treatment, in and
out of sanitariums, without avail. She was brought to me in an invalid's chair. The
first point that impressed me was that the girl did not look ill. I learned that she
commenced to menstruate at thirteen, puberty precipitating an attack of chorea. The
THE HYSTERO-NEUROSES: HYSTERIA.
197
flow never became regular, and was always scanty and very painful. A yellowish
leucorrhea had persisted since her injury. The hip joint was excessively tender upon
pressure, but there was no local increase of temperature, no evidences of fever or
suppuration, and forcible apposition, by striking the heel, was not very painful. More
or less spastic contraction of the flexor muscles of the affected side existed, which
gave to the limb an appearance of shortening, which was very deceptive. The mother
informed me that hysterical symptoms were common. Irritability of the bladder, with
alternate diarrhea and constipation, frequently occurred. On examination I found
the left ovary very tender, with more or less inflammation of the whole genital tract.
The local examination increased the pain in the hip most decidedly, and caused much
nervous agitation. I did not, therefore, deem it wise to recommend local treatment
other than the hot douche with calendula, which was faithfully carried out. I put
around the ankle of the affected leg three pounds of bar-lead, prescribed a pair of
crutches, and insisted upon her walking. The lead was used to overcome the spastic
contraction, as well as for its moral effect. I did not deem the joint lesion of such
a character as to need extension. Ignatia was the only remedy given internally. I
heard nothing more from the case until after my return from a six-months' absence
abroad. She then wrote: "I wore the weight until my left limb was nearly as long
as my right, and can now walk perfectly well with the aid of a cane, though it hurts
me some. I have taken no medicine except the prescription you gave, and have not
deemed it necessary, because of the great improvement." She has now,
three years
later, recovered perfectly, having discarded the cane soon after writing the foregoing
letter.
CASE III.—Distressing Hyperesthesia of Sight and Hearing.—Mrs.
æt. 47,
a widow for twenty years.
She is a devoted church woman and for many years
was a leader in all charitable work done in the community in which she resided.
Through friends she was urged to consult me, and I think that the call to the neigh-
boring town in which she lived was countermanded at least four or five times before
she finally mustered up sufficient courage and strength to see me. Upon reaching
her bed-side I found my patient in a room made dark by closed blinds, over which
were hung heavy blankets to shut out every ray of light. The mirror was turned to-
ward the wall for fear a ray of light might strike it and flash throughout the darkened
room. Nor did the patient rest under these extreme precautions, for the eyes were
protected with two pairs of colored glasses with side attachments. Hyperesthesia of
the sense of hearing was equally marked, and noise was excluded from the room
by double doors whose keyholes were stuffed with cotton. She also had her ears
filled with cotton, over which she wore ear-mufflers. She was emaciated to an ex-
treme degree, and had been reduced to her miserable condition by a series of events
which so frequently precede profound neurasthenia. Her husband was killed during
the war and she was left childless. Twelve months previously to taking to her bed
she nursed her mother through a long and fatal illness. This greatly prostrated her,
yet she kept up until a favorite brother-in-law was thrown from a carriage and killed.
This was the last straw, and the shock compelled her to take to her bed. In due time
loss of appetite with irritability of the stomach developed, which of course led to
marked depravity of nutrition. With the anemia came the hyperesthesia of the
special senses, spinal irritation, headache, hysterical manifestations, etc. There was
no serious pelvic lesion, although she had been much treated for an alleged uterine
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A TEXT-BOOK OF GYNECOLOGY.
displacement with congestion. Unfortunately, she was encouraged instead of discour-
aged in her invalidism and she soon became a nosomaniac of the worst type.
With great difficulty the patient was moved on a couch to a private hospital and
placed under the Weir Mitchell treatment. I ignored the pelvic trouble entirely. It
is unnecessary to give in detail the progress of the case from day to day after this
treatment was inaugurated. Suffice it to say that the improvement was of the most
marked character, and in six weeks from the time she entered the hospital she walked
to her carriage with her eyes and ears unprotected. She soon resumed her church
and charitable work, in which she again finds much enjoyment.
(6) Anesthesia.-Anesthesia may temporarily impair any or all
of the senses. The sense of touch is, however, oftenest affected.
Henrot, Szokalsky, and Gendrin affirm that general or partial
loss of sensibility follows every hysterical attack. So good an
authority as Jolly, however, considers this statement too sweep-
ing. Alternate surfaces of the body are frequently affected, and
hyperesthesia may supplant the anesthesia of the part first
attacked.
All sensations are sometimes absent, but usually that of
pain alone is abolished, while those of heat and pressure
remain normal. The entire surface of the body is rarely im-
plicated. Hemianesthesia occurs oftener on the left side. (Char-
cot.) The most frequent seat, when circumscribed, is the dorsal
surface of the hands and feet and the regions of the outer ankles.
Cases of self mutilation occur in women while in an analgesic
state. Many interesting and almost incredible instances of such
mutilation have been recorded by Cullingworth, Channing, t
Andrews, Jolly, § and others. ||
*
Loss of sensibility of the muscles, bones, and joints may be
* Op. cit., p. 855.
† American Journal of Insanity, January, 1878.
‡ Journal of Mental Science, July, 1875.
? Ziemssen, Vol. xv, p. 507.
|| In one of Dr. Channing's cases the following is a list of articles which were re-
moved from the patient's arm and saved: "Ninety-four pieces of glass, thirty-four
splinters, two tacks, four shoe nails, one pin, and one needle. Several pieces of glass
and the pins and needles first removed were, unfortunately, mislaid and lost. Including
these the whole number of objects removed amounted to one hundred and fifty.
* * * The longest splinter was nearly six inches long." Dr. Channing thinks that
she experienced acute erotic pleasure from the probings to which she was subjected.
THE HYSTERO-NEUROSES: HYSTERIA.
199
associated with the cutaneous anesthesia. Muscular contraction
is only temporarily impaired, if at all; in some instances there
may be difficulty in executing passive movements of the limbs
with the eyes closed.
Anesthesia of the mucous membranes is a frequent symptom in
the hysterical. It may or may not be associated with the
loss of cutaneous sensibility of the neighboring parts. The
mucous membranes of the respiratory, genito-urinary, and
alimentary tracts are the ones most frequently affected, and, as a
result, there is diminution or loss of reflex excitability of the
parts involved. When the rectum and bladder are the organs
implicated the presence of feces or urine fails to create a desire
for evacuation, and the distention often becomes very great
without exciting pain. Scanzoni, in four of his patients, found
complete anesthesia of the vaginal mucous membrane with an
absence of all sexual desire.
Deafness and visual disturbances likewise result from anes-
thesia, occurring particularly in conjunction with hemianesthesia,
and are therefore usually unilateral. (Charcot.) The visual dis-
turbances not infrequently terminate in amblyopia and amaurosis.
An ophthalmic examination rarely discloses any textural change
of the eye.
ALTERATIONS OF MOTILITY.
(a) Clonic and Tonic Spasms.-In dealing with the various
forms of clonic and tonic spasms the same difficulty may present
in distinguishing those that are reflex from those depending
upon direct motor excitation that often presents in distinguishing
a reflex pain from pain due to actual disease. It is often neces-
sary to remove possible causes within the pelvis before an
accurate diagnosis can be made.
Clonic or tonic spasms of hysterical origin may implicate any
muscle or muscles of the body. When the pharynx is involved
it gives rise to that peculiar sensation known as globus hystericus.
(Hammond.) Other writers attribute the peculiar sensation so
often felt in the throat to a reversed peristalsis of the esophagus.
(Jolly.) Eulenberg considers it a sensory and not a motor
phenomenon. It is certain that the esophagus is frequently the
seat of hysterical spasm which, under certain circumstances,
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continues long enough to simulate organic stricture. A similar
spasm not infrequently implicates the stomach, intestines, and
bladder.
A tonic spasm of the limbs causes contractions, a symptom,
which, especially when accompanied with paralysis, suggests very
forcibly the possibility of organic lesion. These contractions
may last for an indefinite length of time. Charcot cites a case
of eighteen years standing. The patient was first seized with
an hysterical paroxysm which was followed by paraplegia and
contraction. Hammond says he has frequently seen such con-
tractions last for several months.
mon.
(b) Paralyses.-So-called hysterical paralysis is not uncom-
It is either restricted to individual muscles, or occurs, as
it oftener does, in the form of hemiplegia. Hysterical aphonia,
coming and going suddenly, is due to paralysis of one or more
of the laryngeal muscles. However, aphonia due to reflex
causes, may and often does persist until the cause is removed.
Reflex paraplegia may be partial or complete. If the lower
extremities are involved, and the paralysis is incomplete, the
patient has a peculiar gait, unlike that of any organic disease of
the cord. By the aid of crutches or articles of furniture within
her reach she drags her limbs along. As in all hysterical affec-
tions, her ability to walk is very variable, depending much on
external circumstances, as well as the state of her own mind.
CASE IV.-Reflex Paraplegia, Due to Anteversion and Urethral Fissure.-Mrs.
W., æt. 33, Muskegon, Michigan, presented herself at my clinic October 7, 1886,
with symptoms of locomotor-ataxia. Married for twelve years. Never pregnant.
Illness dates back for six years. First noticed inability to mount staircase owing to
weakness and tremor of limbs. Could not walk unless looking at feet, and couldn't
stand with eyes closed. There was a burning pain over the sacrum. Urination pain-
ful and frequent, the bladder being emptied many times during the twenty-four hours.
The urine was perfectly normal. Feet and hands cold. The uterus was anteverted,
and the urethroscope showed a fissure at the neck of the bladder. The dysuria was
entirely overcome by forcible dilatation of the urethra, after which an anteversion
pessary was fitted, argentum nit., 6x, given internally, and the Faradic current
applied once per day. She returned home December 3d much improved, though not
well. I have not been able to hear from her since. I should have added that elec-
tricity had been faithfully used before coming to me. The rôle played by the argen-
tum nitricum should not be underestimated, for the indications were clear cut, and
it covered the case beautifully.
THE HYSTERO-NEUROSES: HYSTERIA.
201
CIRCULATORY DISTURBANCES.
General Considerations.-In another place* I have endeav-
ored to show the important and intimate connection existing
between the generative organs and the vaso-motor system of
nerves. Inasmuch as the vaso-motor system presides over the
circulation, it is certainly not remarkable that the circulatory
equilibrium should be upset by utero-ovarian disease. Dilata-
tion and contraction of the vessels and capillaries result in
response to a peripheral stimulus, so that no system is more
quickly implicated as a result of reflex impressions than the
circulatory. The cold pallor of contracted, and the hot flush of
dilated, capillaries are symptoms frequently witnessed when the
utero-ovarian functions are disturbed, as during the change of
Such disturbances may be either (a) central or cardiac;
or (¿) peripheral or vascular.
life.
(a) Central or Cardiac.-In the August, 1886, number of the
American Journal of Obstetrics will be found a most excellent
article by H. J. Bolt, M. D., entitled "Cardiac Neuroses in Con-
nection with Ovarian and Uterine Disease." Doctor Bolt states
in this article that cardiac neuroses are present in eight per cent.
of all cases of uterine disease, and classifies them as follows:
1. Palpitation;
2. A disturbance of the rhythm (irregularity);
3. A distinct suspension of a distinct beat (intermittence);
4. Angina pectoris.
Palpitation of the Heart is a common symptom resulting
from pelvic lesions, and, frequently, the only one of which the
patient complains; at least it so absorbs her attention and excites
her apprehension as to make her oblivious to all other incon-
veniences. It is always made worse by nervous excitement, as
the heart's action in no small degree is governed by the emotions
and the state of the mind. Pain frequently accompanies the
palpitation, sometimes extending to the left shoulder and down
the left arm. It may be sufficiently severe to amount to an
angina pectoris.
* Chapter VIII.
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A TEXT-BOOK OF GYNECOLOGY.
The palpitation is generally paroxysmal in character, though
it may be continuous. It often occurs immediately upon lying
down at night, preventing the patient from getting to sleep; or
it is worse during digestion. The sensation of palpitation is
frequently much greater than it really is, so that the patient
complains of the violence of the heart's action when indeed it is
normal, or but little disturbed. This can be accounted for only
by the increased sensitiveness of the heart and the surrounding
structures, thus making the patient painfully conscious of the
ordinary movements of the organ. (Byford.)
Intermittency and irregularity of the heart's action, though not
a frequent neurosis, does sometimes result from a "modification
of the rhythmic discharge in the cardiac ganglia." (Bolt.) It
stands to reason that a reflex palpitation existing for an
indefinite length of time is capable of producing an organic
lesion of the heart, which would thus no longer be a pure
neurosis. I believe, however, that disturbance of rhythm is
often, and that intermittency is occasionally, the result of
uterine disease.
Loomis* affirms that angina pectoris is always the result of
organic heart disease. Fothergill, Peabody, and Fluck,† on the
other hand, maintain that angina pectoris without organic disease
is a possibility. Admitting that, in at least the larger number
of instances, the symptom is the result of an evident organic
lesion, the fact remains that in a limited number of cases of
suspected organic disease, with severe anginal symptoms, an
autopsy reveals no demonstrable disease.
(6) Peripheral or Vascular.-The phenomena referable to
reflex disturbance of the peripheral circulatory system result
from the irregularity of distribution of the blood. Flushes of
heat, undue redness of the face, cold hands and feet, a sensation
of heat located on the top of the head, or in the occipital region,
or extending into the spine, burning in the sacrum and loins, etc.,
are symptoms due to vaso-motor disturbance. If the vaso-motor
paralysis is limited small blotches of erythema, perhaps not
* "Practical Medicine,” p. 504.
+"Pepper's System of Medicine,” Vol. 1, p. 750.
THE HYSTERO-NEUROSES: HYSTERIA.
203
larger than a fifty-cent piece, may appear upon any portion of
the body—the back, chest, face, or limbs. Ecchymoses smaller
than the erythematous spots are occasionally seen. These
symptoms occur not infrequently in conjunction with morbid
perspirations. (Tilt.)
The symptoms enumerated occur more frequently during the
menopause than at any other time, and cannot always be justly
relegated to the category of hystero-neuroses. They are un-
doubtedly many times due to increased intra-arterial pressure,
the result of the cessation of menstruation. In proof of this
the same symptoms sometimes follow oophorectomy in young
and middle aged women. An hyperesthesia of the mucous
membrane in the region of the internal os is, however, usually
present when these symptoms persist, and they will often vanish
as by magic after dilatation and curetting. Lesions of the
rectum may likewise perpetuate vascular disturbances. The
several forms of vicarious hemorrhages are dealt with in another
chapter.
Illustrative Cases.
CASE V.-Cardiac Neurosis resulting in Organic Disease associated with and prob-
ably caused by laceration of the cervix. Greatly relieved by Emmet's operation.—
Mrs. W. was brought to my clinic on November 30th, 1886, by her physician,
Dr. Wheelock of Bancroft, Michigan. She was 51 years of age, possessed a good
family history except that one sister suffered from periodical attacks of insanity. Has
had four children. She did not get up well from the birth of her last child, soon
after which she began to have severe attacks of palpitation, which were always
worse during menstruation. An examination of the heart revealed undoubted dilata-
tion and great irregularity. The uterus was prolapsed, enormously swollen and con-
gested, the lips everted and so greatly hypertrophied as to almost present externally.
The hypertrophy was so great as to make partial amputation necessary. Much cica-
tricial tissue was removed. The patient nearly died during the operation from the
effects of ether; however, she made a splendid recovery, and for two years her health
was infinitely better. The heart symptoms improved simultaneously with the local
improvement, but because of the organic changes never entirely disappeared. She
died two years subsequent to the operation, after some undue exertion, from heart
failure.
CASE VI.-Cardiac Neurosis simulating Exophthalmic Goiter caused by retroversion
and endometritis.-L. M., æt. 40, unmarried. Had for years suffered from local
pelvic distress, leucorrhea, bearing-down pain, backache, occipital headache, etc. She
came to me during the month of April, 1886, because of a severe palpitation
of the heart which had persisted for six months or longer. The pulse ranged from
120-160 beats per minute. The eyes were very prominent, one being more so than
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the other. There was suspicious enlargement of the thyroid. An examination re-
vealed a retroversion with more or less chronic endometritis, both cervical and cor-
poreal. I reposited the uterus, fitted a Hodge pessary and cured, by appropriate treat-
ment, the inflammatory condition. Gelsemium, cimicifuga and kali carbonicum were
given internally. In six months' time the heart's action became perfectly normal and
the thyroid returned to its natural size. The eye symptoms still persist in spite of the
best directed efforts of some of the most prominent oculists in America.
CASE VII.-Cardiac Pain simulating Angina Pectoris due to pelvic lesions.—Mrs.
M., æt. 29. Married eleven years; never pregnant; menstruation began at 12 years.
The present trouble dates from the time of matrimony. Was said to have inflamma-
tion of the womb four years ago. Complains principally of pain in the heart, which is
described as paroxysms of " piercing and sticking,” and in the intervals as a dull con-
tinuous pain, which traverses down the left arm. Two tender points are present on
pressure over the precordia. Dysmenorrhea and other symptoms are present which
point to uterine trouble.
Diagnosis.—Retroversion of the portio vaginalis, with the body of the uterus pushed
slightly to the left. An old exudation is felt on the right side. Chronic endometritis.
Patient cured on directing treatment to pelvis.-Dr. H. J. Bolt, in the American
Journal of Obstetrics.
CASE VIII.-Circumscribed Erythema of the Lower Limbs in a young hysterical girl
of 18. Retroversion. Cured.—The patient, of German parentage and not particu-
larly intelligent, was, I am convinced, an onanist. The most striking symptom was
the appearance, about four days previous to each menstruation, of two erythematous
patches on the anterior thigh of each side, midway between the knee and body.
These patches were perfectly symmetrical and about the size of a silver dollar. The
patient was entirely cured by correcting the uterine displacement.
CASE IX.-Menorrhagia with marked Vaso-motor Disturbances cured by dilating
the cervix and curetting.—Mrs. A., æt. 51. Married. Profuse menorrhagia, recur-
ring about every six weeks. During the intervals vaso-motor disturbances of all
kinds-cold hands and feet, flushes of heat, alternate redness and paleness of the
face, oppression of breathing, etc. The uterus was greatly subinvoluted and the
mucous membrane at the internal os most exquisitely sensitive. Entirely cured of
all hemorrhage and nervous symptoms by forcible dilatation, curetting, and the
application of iodin. Lachesis had modified the nervous phenomena previously to
the operation, but only gave temporary relief.
ANOMALIES OF SECRETION AND EXCRETION.
Urine. The secretion of a large quantity of limpid and
almost odorless urine frequently results from nervous excite-
The physical character depends upon the excess of
water and the deficiency of salts. Again, in uterine patients,
the salts may be increased in quantity and the water diminished.
When the urine is decidedly morbid in its composition, how-
THE HYSTERO-NEUROSES: HYSTERIA.
205
ever, it is usually secondary to gastric and hepatic derangements.
Abnormality of the urine, especially if it be excessively acid or
alkaline, frequently excites painful micturition. It may be
greatly diminished or almost absent instead of increased in
quantity.
Salivation. Both salivation and abnormal dryness of the
mouth have been observed in hysterical and uterine patients.
Dr. H. W. Longyear of Detroit, has reported a case of "per.
sistent salivation, apparently due to laceration of the cervix
uteri." The profuse flow of saliva, which had persisted for more
than a year, was only cured by closing a rent in the cervix. Dr.
Babcock of Jamestown, N. Y., consulted me in regard to a similar
case.† After an hysterical paroxysm, the salivation may be
apparent only, escaping from the mouth because, owing to spasm
or paralysis of the pharynx, it cannot be swallowed. (Valen-
tiner.) Salivation is frequently associated with pregnancy, and
may be the first warning which the patient has of her condition.
Abnormal and anomalous secretions may proceed from the
uterus, the vagina, the breasts, the liver, the stomach, and the
bowels. As a result of utero-ovarian disease a vicarious leucor-
rhea is not uncommon and is dealt with in the succeeding
chapter. Those arising from the other organs will in due time
be considered seriatim.
Disorders oF RESPIRATION.
The painful spasm in the region of the throat has already
been referred to under the designation of globus hystericus.
This feeling of constriction often gives rise to obstructed respi-
ration, inducing a fear of fatal suffocation. Again there may be
a sensation as if smoke or dust were being inhaled. Engel-
mann cites many interesting reflexes of the respiratory organs
resulting from pelvic lesions-pharyngitis, tonsilitis, bronchitis,
asthma, etc. Byford says he has seen "imperfect respiration or
* American Journal of Obstetrics, January, 1883.
† I have within the last week operated upon a woman, aged forty-two, for laceration
of the cervix and complete laceration of the perineum, who has for two years been
greatly annoyed by a profuse salivation. The case is yet too recent to note the
effect of the operation.
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""
partial inflation of one lung, or parts of the lungs in the
hystero-neurotic. When this condition is associated with a
cough, which in some women is exceedingly persistent, it gives
rise to much concern. A reflex asthma is sometimes most
distressing and obstinate, and does not always disappear after
the local cause is removed.
Illustrative Cases.
CASE X.-Hysterical Cough, with Anteflexion and Dysmenorrhea.-Patient æt. 18,
German. Hysterical paroxysms have been frequent. At each menstrual period she
suffered from a persistent dry, hacking cough, which was kept up while awake during
the entire menstrual period. I deemed a local examination advisable, but upon
attempting one the cough was greatly aggravated. However, I succeeded in
diagnosing an anteflexion. Because of the nervous and erotic symptoms excited
by the examination I did not deem it wise to resort to local treatment. The cough
continued to recur for twelve months, when it gradually disappeared.
CASE XI.—Reflex Asthma Temporarily Cured by the Removal of the Appendages
of One Side. Recurrence and the Removal of the Appendages of the Other Side.
Recurrence of Asthmatic Attacks after a Respite of Three Months.—Miss C., æt. 40,
Owasso, Michigan. I was requested to see this patient by her physician, Doctor B.
F. Knapp, while making a professional visit to Owasso for another purpose. The
patient had been in poor health for three years, suffering from an ovarian displacement,
and as all efforts at reposition were without avail, she presented herself at our college
clinic on October 19, 1887. Three years previously to this date, while picking peaches,
she felt something "give way" in the region of the pelvis, causing some pain, which
was relieved by steady pressure over the pubes; following this accident she suffered
after each stool the most excruciating pain, which was bearing-down in character and
frequently excited nausea. This pain lasted for an hour or longer, extending into
the spine, and, owing to its severity, defecation was delayed until constipation had
become chronic, cathartics and enemata being always necessary to move the bowels.
Dysmenorrhea was a prominent symptom, the pain preceding the menstrual flow for
two or three days. A reflex asthma during the period was a frequent complication,
during which the respiration was greatly embarrassed, the skin bathed with cold,
clammy perspiration, the pulse weak and thread-like, and the features drawn and con-
tracted. A digital examination revealed a tumor in the posterior cul-de-sac, which
counter-tests proved to be the left ovary. The bimanual showed the right ovary to be
in its normal position and seemingly healthy. The prolapsed ovary, however, was
enlarged to twice or thrice its normal size, and was exquisitely tender. All efforts
made to return the displaced organ to its normal position were futile. The patient
was ordered a hot vaginal douche twice a day, with a tampon made from flaxseed
tied in a small muslin bag, dipped in hot water, and gently placed in the posterior
vaginal fornix. Nux vomica 3x was prescribed four times a day.
November 3, 1887. Being satisfied that nothing short of a radical operation would
afford permanent relief, I removed the offending organ through the abdomen. The
ovary was adhered to the floor of the posterior cul-de-sac, though the adhesions were
THE HYSTERO-NEUROSES: HYSTERIA.
207
separated with little difficulty. The abdominal walls were unusually thick, and some
difficulty was experienced in withdrawing the ovary far enough to include both the
ovary and the tube in a Staffordshire knot. The right ovary and tube seemed per-
fectly normal, and were, very unwisely, left behind. The abdominal wound was closed
in the ordinary way, and the patient placed in bed. Briefly, her history from the
above date to January 11th was as follows: Convalescence progressed favorably
for two weeks, the temperature not exceeding 100° and this elevation could be
accounted for by more or less irritation of the abdominal wound. The patient for a
time even felt much relieved. At her next menstrual period, however, she suffered
an unusual degree of pain, the temperature reaching 102°. All of the old symptoms
of strangury and pain after defecation returned with increased severity. The asth-
matic attacks recurred very much oftener than ever before, and prostration was cor-
respondingly great. A vaginal examination revealed the right ovary in the same
locality formerly occupied by the left. It, too, was enlarged and tender. In short,
the intra-peritoneal irritation incident to the removal of the left ovary had set up an
inflammation of the appendage left behind, resulting in its prolapse and adhesion.
She very gladly submitted to the second operation, which was done on January 11th,
just two months and nine days after the first. An incision was made a little to the
right of the old cicatrix, the ovary separated from the floor of the cul-de-sac, tied as in
the former case, and removed with the tube. The first ovary had undergone cystic
degeneration, and the tube was distended with water; the last presented all of the
evidences of subacute inflammation, a small circumscribed abscess containing perhaps
a teaspoonful of pus occupying a portion of its stroma. Convalescence was almost, if
not quite, uninterrupted after the second operation; the abdominal wall, owing to its
excessive thickness, causing the only impediment. The bowels were moved on the
third day with little or no pain, and soon became perfectly regular. Under the date
of March 1st she writes: "I am feeling better than I have for years. My bowels are
perfectly regular, and I have no more of those nervous spells. I enjoy visiting with
my friends very much, and cannot thank you sufficiently for what you have done for
me."'*
CASE XII.—Reflex Asthma of Eighteen Years Standing. Cured by Removing
Prolapsed Tissue from the Urethra.—Mrs. S., æt. 47, sent to me by Dr. S. L. Porter
of Vernon, Mich. Married for 26 years, and has given birth to three children, the
eldest being 25 and the youngest ten years of age. Her present trouble dates from
the birth of her second child, 18 years ago. Dysuria has persisted ever since.
The patient was haggard and emaciated from her extreme suffering. A severe
asthma, recurring at variable intervals, persisted during the entire 18 years. Upon
local examination I found an exquisitely sensitive and tender tumor as large as a
pullet's egg, completely surrounding the external meatus of the urethra. This was
* In a letter dated December 31, 1890, the patient reports herself as bad as
ever, so far as the asthmatic attacks are concerned. If the asthma was a genital-
reflex, its persistence can be explained only upon the theory that the nerve terminals
are still involved in the cicatrix. I record the case under this head to show how
extremely difficult it is to determine the reflex origin of any symptom without first
removing the local lesion.
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+
ligated and removed. I never witnessed more rapid and greater improvement than
ensued. She began to gain at once, and she never suffered from an asthmatic attack
after the operation. She gained in flesh 25 pounds in three months. I heard from
her in December of 1890, five years after the operation, at which time there had
been no recurrence of the old symptoms.
CASE XIII.-Reflex Aphonia · Resulting from Pelvic Inflammation with Involve-
ment of the Appendages. Cured by Salpingo-oöphorectomy.—Patient sent to me by
Dr. W. H. Frost of Tecumseh, Mich.; æt. 42; unmarried. She came to my clinic
February 18, 1888. She was bed-ridden, could not stand on her feet, and had had
absolute aphonia for 12 years, dating from an attack of typhoid fever, with
probable pelvic complication. At any rate, her pelvis was a mass of inflammatory
exudates; there was menorrhagia, which added each month to the anemia, already
profound. Menstruation was very painful. Salpingo-oöphorectomy was performed
and recovery from the operation progressed without any untoward symptoms. The
patient surprised us all by talking the day following the operation. Her general
health began to improve, she got on her feet, and in six weeks returned home nearly
well. This favorable condition continued for six months, when, owing to imprudence
because of her favorable progress, she was taken with peritonitis and died. Her
imprudence consisted in walking several miles during inclement weather to a family
reunion.
CHAPTER XV.
THE HYSTERO-NEUROSES: HYSTERIA.
(Continued.)
DISORDERS OF THE GASTRO-INTESTINAL CANAL.
Gastric Neuroses.-The vagus is a bridge which unites the
central portions of both nervous systems. (Tilt.) It is not well
isolated and resembles both. By anastomosing with the sym-
pathetic it helps to form the celiac plexus, so that when it be-
comes deranged the epigastric ganglia sympathize. As a result
the viscera, through their ganglia, react upon the brain, caus-
ing paralysis of the epigastric centers. In this way the appetite
becomes perverted, and often there is in the gastric region a
feeling of sinking and faintness; or there may be gaseous dis-
tention of the stomach with belching and nausea and vomiting.
Indeed, indigestion and symptoms of gastritis frequently result
from either morbid or physiological changes in the reproductive
organs. The nausea and vomiting of pregnancy occur in
response to a physiological change of these organs-or rather
they often present themselves when local morbid conditions are
not demonstrable. In due time the nutrition becomes seriously
affected because of the indigestion.
So-called hysterical vomiting may be a most distressing and
persistent symptom. At times it is apparently due to an increase
of the gastric secretion, as fasting patients will eject enormous
quantities of fluid. Again it may be a vicarious act on the part
of the stomach, as both Charcot and Fernet have found urea in
the vomited matter.
A gastric neurosis is differentiated from organic disease of the
stomach by observing the following points:-
1. The symptoms subside upon curing the local lesion.
2. Articles of diet which would aggravate organic lesions are
frequently the only ones retained in a neurosis.
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3. Exacerbation of the gastric symptoms occurs simultaneously
with an exacerbation of the pelvic symptoms.
implicate the
4. Entire absence of the evidences of organic disease.
Intestinal Neuroses.-The intestinal secretions may be defi-
cient or excessive in uterine disease, giving rise either to consti-
pation or diarrhea. The constipation is sometimes exceedingly
obstinate, there being no tendency for the bowels to move with-
out artificial aid. The diarrhea and constipation frequently
alternate. When due to deficient secretion, the stools are dry
and hard; when due to deficient peristaltic action, they are per-
fectly normal as regards consistence, color, etc.
Both hyperesthesia and anesthesia frequently
mucous membrane of the gastro-intestinal canal. With the first,
everything that comes in contact with the mucous membrane
excites contraction and induces pain. Food may be ejected
before passing into the intestine; if it is not, its presence in the
intestine excites exaggerated peristalsis, and the food is hurried
on through the canal before it is digested. Frequent evacua-
tions of the bowel are thus induced. Should the hypersensi-
tiveness be limited to the rectum, great distress is caused by the
presence of the slightest amount of fecal matter. In a chapter
entitled "The Rectum and Defecation in Hysteria,"* Weir
Mitchell records a case so bad that the patient was compelled
to wear a napkin over the anus, notwithstanding that the stools
were normal in consistence.
In anesthesia there is deficient instead of exaggerated peristal-
sis. It may amount to almost a paralysis of the intestinal canal,
although the anesthesia is usually limited to the lower intestine.
Enormous accumulations of perfectly-formed fecal matter may
lodge in the whole lower half of the descending colon, or merely
in the sigmoid flexure. So obstinate is the retention that a
stricture is sometimes suspected.
Diarrhea, with profuse, watery and exhausting discharges,
occasionally accompanies uterine disease. The kind of ingesta
seems to have but little influence upon the discharge, and an
attack is particularly liable to occur during menstruation.
* "Nervous Diseases," p. 252.
THE HYSTERO-NEUROSES: HYSTERIA.
2II
Gaseous distention of the intestines is likewise a frequent
symptom of uterine disease. It is often tumultuous, and the
distention may be so great as to give rise to symptoms of
pregnancy. During the hysterical paroxysm it not infrequently
becomes a prominent and most distressing feature of the attack.
Byford calls attention to the expulsion of muco-fibrinous casts
from the intestinal canal as a result of uterine disease-a symp-
tom which I have observed in a number of cases. It is a sort
of membranous enteritis, and the quantity of casts discharged at
one time may be very great. They consist either of shreds of
mucous membrane or complete casts of the intestinal tube. I
am not aware that any other author mentions these casts in
connection with uterine disease. The cases observed by me
recovered fully after the pelvic trouble disappeared.
The gastro-intestinal reflexes are likewise frequently excited by
rectal lesions. The gynecologist who ignores this fact will often
fail ignominiously in his attempts to relieve his patients.
Illustrative Cases.
CASE XIV.-Acute Vomiting for Two Years, due to Anteflexion of the Uterus.—
Patient æt. 25. Had suffered during the entire two years from almost incessant
vomiting and occasional hematemesis. The uterus was found soft and anteflexed
(with posterior rotation). Suitable treatment in a short time completely removed the
vomiting.-Hewitt.
CASE XV.—Membranous Enteritis during Climaxis.—Patient æt. 48; married;
has had four children. Was bed-ridden for nearly two years with general nervous
prostration. I was called to see this patient after she had been in bed for nearly a
year. Menstruation had ceased, but the psychoses were very prominent and insanity
was greatly feared. For nearly ten months after I saw her she passed enormous
quantities of membranous masses, which were sometimes discharged in the form of a
ball resembling parasites. There was chronic metritis. After the symptoms incident
to the menopause disappeared she made a complete recovery.
•
CASE XVI.—Reflex Intestinal Neurosis.-Miss H., æt. 15, under treatment for
vesical weakness, is suffering from nervous prostration. The patient had been
affected with habitual constipation, which yielded but slowly to treatment. For a few
days before the appearance of the first flow, I believed that a natural action of the
bowels had been accomplished and a healthy tone restored; the constipation seemed
overcome. After the cessation of the flow the previously existing conditions were
reëstablished. With the advent of the second menstrual period the patient was
seized with a diarrhea, uncontrollable at times, so that I found her in tears from
mortification at her distressing state. One passage followed another. This annoying
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reflex persisted during the two days previous to the flow, yielding to constipation
during its continuance, and returning again for 36 hours after cessation of the
The third period was accompanied by the same symptoms, together with
numerous other reflexes.-Engelmann.
menses.
Disorders of THE SKIN (Dermatoses).
In studying nervous lesions and nervous phenomena it is par-
ticularly difficult to distinguish between coincidences and actual
effects. This is especially true in dealing with the so-called
dermatoses. Some of the tests applied to other forms of hystero-
neuroses must be applied with a certain degree of reservation in
skin diseases. It has been shown that nearly if not quite all of the
hystero-neuroses are aggravated by menstruation, and the der-
matoses form no exception to this rule; but most skin diseases,
of whatever origin, are made worse by any cause which intensi-
fies the hyperemia of the skin, and menstruation will do this. It
is, therefore, no sign of its uterine origin that a skin affection
is made worse by menstruation. However, testimony is not
wanting which conclusively proves that the utero-ovarian func-
tion exerts no small influence upon the skin, both for good and
for evil. The acne of puberty and the pigmentation of preg-
nancy are recognized by all as dependent upon physiological
changes within the pelvis. The symmetry of these changes
points unmistakably to their nervous origin. Thus Godson
cites a case, which is quoted by Engelmann, of a girl sent to St.
Bartholomew's Hospital for chorea in her seventh month of
pregnancy; the areola of both breasts were perfectly formed,
except about one-third of their circumference, which was per-
fectly free from discoloration. The area was sharply limited
and almost exactly symmetrical on the two sides. Barnes, in
commenting upon this case, remarks that it is inconceivable how
any difference in the quality of the blood going to the parts
could exist. Engelmann observes that it is upon the larger
surfaces of the body where the most peculiar and symmetrical
configurations are traced, precisely the same on both sides, but
that they often escape observation because concealed by the
clothing or bedding. While, then, it is true that pigmentation
and other forms of skin disease may often depend upon changes
THE HYSTERO-NEUROSES: HYSTERIA.
213
within the circulatory system, there is indisputable evidence
bearing upon the utero-ovarian origin of many cases which have
been cured only by directing the treatment to the local cause.
Space will permit me to do nothing more than enumerate some
of the varieties of dermatoses of pelvic origin, giving, by way of
illustration, two clinical cases. Erythema, acne, pigmentation,
pustules, sallowness, flushes, seborrhea, etc., are common affec-
tions, made worse by conditions which exacerbate the local mis-
chief, and disappearing only after the local disease is cured.
Behrend, Wagner, and Steller report cases of herpes, ecchymoses,
hemorrhagic nodules, etc., of uterine origin. Engelmann devotes
considerable space to recording in detail histories of melasma,
acne rosacea, and erysipelas. Indeed, almost any of the derma-
toid diseases may, according to these writers, have their origin
in the reproductive organs.
The genito-reflex neuroses of the skin, unlike all others, rep-
resent actual and not phantom disease. Nevertheless they differ
from actual disease produced by other causes inasmuch as they
fail to yield either to general or direct medication.
The fact that actual skin lesions are produced in a reflex
way can only be explained by the knowledge that through the
vaso-motor nerves the circulatory and glandular systems are
both involved. The skin "is the safety-valve of the system,"
and the acne of puberty, the seborrhea of menstrual irregu-
larity, the flushes and sweats of the menopause, are often but
external manifestations of a disturbed equilibrium, acting
through the sympathetic system.
Illustrative Cases.
CASE XVII.-Eczema of the Face, of Five Years Standing, Cured by Operating
upon the Perineum and Cervix.-æt. 35.-Married and the mother of five children.
Patient came to me with a most obstinate eczema squamosum, dating from the birth of
her last child, four years previously to consulting me. This remained invulnerable to both
general treatment and local applications. I found upon making a pelvic examination
a cervical laceration with much relaxation of the pelvic floor. Other reflex symptoms
were present, including a most persistent occipital headache. Swooning and faintness
just before the menstrual onset commonly occurred and the patient's friends greatly
feared serious heart trouble. I removed from the cervix an incredible amount of
cicatricial tissue, invading the broad ligaments on either side. The pelvic relaxa-
tion was overcome by Emmet's perineal operation. For three months the patient did
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not improve, but from that time on she rapidly gained in every way, and one year
from the date of the operation was in perfect health.
from
CASE XVIII.-Acne Pustule on the Side of the Nose, Recurring with each Men-
strual Period. Anteflexion, Endometritis, and Perimetritis.-Miss C
Texas, 26 years of age, long afflicted with vesical pains, the result of pressure of an
anteflexed uterus, menstrual suffering and great nervous depression, was much annoyed
by an acne pustule which appeared for three successive menstrual periods upon one
and the same place, on the right side of the nose, but ceased to come, with decided
improvement in both the position of the organ and the catarrhal inflammation.—En-
gelmann.
GLANDULAR DISTURBANCES.
Under the head of "Anomalies of Secretion," profuse salivation
and urination have been referred to as symptoms indicating reflex
disturbance of the parotid glands and of the kidneys. As
further evidence of the sympathy existing between the repro-
ductive organs and the salivary glands, it is only necessary to
refer to the frequency of the metastasis of mumps to the genera-
tive organs of both sexes. In the male it is the testes which
become involved secondarily; in the female the ovaries, the
mammary bodies and the uterus. Again parotid buboes are not
unknown after ovariotomy, when no evidences of sepsis exist
(Schroeder); and Goodell reports a case of swelling of the par-
otid gland coming on two weeks after a trachelorrhaphy and
persisting for nearly two years. Cases of diminution of the
salivary secretion, of undoubted uterine origin, have been re-
corded by both Engelmann and Goodell, so that, to use the words
of the latter, there undoubtedly exists "a kinship of sympathy
between the parotid glands and the adult sexual apparatus."
The Liver.—Unfortunately we are not in possession of the
same reliable data proving a direct sympathetic relationship be-
tween the liver and the pelvic organs as between the salivary
glands and those organs. In proof of the fact that central lesions
may exert an influence upon the liver, it is only necessary to
quote the old experiments of Claude Bernard, in pricking the
floor of the fourth ventricle, whereby sugar was produced in the
liver; or to refer to the frequent attacks of icterus caused by
fright, grief, anger, etc. The exact cause of the glycosuria of
pregnancy is as yet unknown, but the fact that it disappears
entirely as time advances argues against organic lesion of the
THE HYSTERO-NEUROSES: HYSTERIA.
215
nerve structures. It is not unreasonable to believe that uterine
stimulation, either through the medulla oblongata or by direct
ganglionic connection, may act upon the liver in such a way as
to interfere with its glycogenic function. Be this as it may,
every physician of experience has observed many cases of
hepatic disturbance associated with uterine disease which disap-
peared only upon curing the latter. Possibly this may be due to
the fact that the treatment adopted, both general and local,
improves the quality of the blood passing through the liver.
Reasoning from analogy, however, it seems unwise to ignore
pelvic reflexes in dealing with hepatic diseases.
CASE XIX.-Hystero-neurosis of the Liver, Simulating" Gall Stones," Cured by
Directing Attention to the Pelvis.—Mrs. L.—, æt. 43. Married and the mother of
five children. She is a large, fleshy woman with none of the neurotic element in
her make-up. For six consecutive menstrual periods she suffered from all of the
symptoms of biliary colic. She would be taken suddenly with the most excruciating
pains in the region of the liver, with local tenderness. Nausea and vomiting fre-
quently supervened. These pains would last until the flow became somewhat pro-
fuse and then gradually disappear-not infrequently lasting for twenty-four hours.
The dysmenorrhea was not marked, nor were there any symptoms pointing to pelvic
mischief, except a slight leucorrhea. However, after hunting in vain for gall-stones
in the feces, I decided, much to the patient's disgust, to look to the pelvis. A retro-
displacement was found and corrected, and in the course of two months she be-
came pregnant. There has been no return of the trouble for six years.
Thyroid Gland.—It is said that before and after the nuptial
night the Roman matron cast a fillet around the bride's throat;
if the marriage had been consummated the thyroid was found
swollen on the following morning. Even in our day, says
Goodell, horse breeders measure the necks of their mares before
and after they have been covered, to determine whether or not they
have conceived. As a sign of pregnancy the presence or absence.
of swelling of the thyroid is no longer considered reliable, but as
a matter of history, it shows that the ancients long ago recognized
genital reflexes. I have two patients who are first apprised
of conception by a swelling of the thyroid. The frequency of
goiter at or about the time of puberty—often disappearing spon-
taneously after menstruation is fully established-points very
significantly to the probable influence exerted by the generative
organs upon this gland. At any rate, in dealing with goiter in
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girls and women, it is wise to bear in mind the evidence in our
possession.
Mammary Glands.-The mammary bodies are often highly
excited by uterine disease. This is not strange when we
consider the connection existing between them and the sexual
organs. Indeed, they constitute a part of the reproductive
system, partaking of the same physiological changes incident
to puberty, pregnancy, and the menopause; therefore, patho-
logical changes within the pelvis very naturally react upon them.
The most common sympathetic condition is congestion, whereby
the mammæ increase in size and become hot and painful.
Sometimes these symptoms are purely subjective, an examina-
tion revealing no perceptible alteration in the glands. Actual
inflammation, even extending to the axillary glands, may
supervene, and I believe that neoplasms occasionally arise from
such irritation. In at least two cases I have removed the breast
in suspicious enlargement, when the microscope revealed nothing
but inflammatory infiltration. In both instances there was
serious pelvic mischief, and the mammary irritation dated from
the onset of the latter.
DISORDERS OF THE NERVOUS SYSTEM.
Under different heads many of the hystero-neuroses giving
rise to pain and paralyses have already been considered. There
yet remains to be enumerated a class of mental symptoms arising
from disorder or disease of the uterus and its annexa which are
known as hystero-psychoses; and a class of nervous affections
characterized by paroxysms and loss of consciousness-hystero-
and true epilepsy, and hysteria.
The milder forms of hystero-psychoses manifest themselves in a
slight melancholia with insomnia, loss of memory, fretfulness
and an indescribable dread of some unforeseen calamity. In the
severer types the melancholia is much more profound, and even
mania may develop.* Moral perversions are likewise often
* During the last six months I have seen with Dr. Barton of Ypsilanti, a case of
profound suicidal mania which was entirely relieved by overcoming a badly retroflexed
uterus.
THE HYSTERO-NEUROSES: HYSTERIA.
217
met with, due to disturbance within the pelvis. It is high time
that alienists give to this subject the attention which its impor-
tance justifies.
Epilepsy as a Hystero-Neurosis.*-The most important
distinction to be made between a true central lesion and a
ganglionic reflex is the unfavorable prognosis of the one and
the favorable prognosis of the other. An accurate diagnosis is,
unfortunately, often impossible before an operation or before
treatment has been resorted to. It is owing to this fact that we
are unable to select reflex epilepsies with unerring certainty.
We are led to suspect the utero-ovarian origin of epilepsy if it
recurs at each menstrual period and if we discover actual disease
of these organs, but we cannot be positive until the offending
organ
is removed or restored to a normal condition. Even then
that which, for want of a better explanation, we designate as
“habit” may have so impressed itself upon the nervous centers
as to continue operative after the primary lesion is overcome;
or, the irritation of a nerve fiber may continue even after the
diseased organ has been removed. In this there is nothing
remarkable, since similar phenomena constantly occur under
other circumstances. Thus, menstruation will sometimes persist
in a vicarious form long after the entire uterus and its appen-
dages have been removed; an epilepsy undoubtedly due to a
depression of the skull will not always cease after the condition
of depression has been remedied; and an imaginary pain will
recur in a foot after the limb has been amputated for years.
The first two illustrations are examples of " habit;" the last, an
example of the continuance of irritation by the compression of
terminal nerve-fibers at the point of amputation. And so, it is
reasonable to believe, an epilepsy primarily due to utero-ovarian
lesion may be perpetuated, even though the original lesion be
cured, or the offending organ removed.
I am fully aware that removal of the appendages for true
epilepsy is looked upon with much distrust, and, in the light of
the data at our command, justly so. I am confident, however,
* v. Paper presented by the author to the International Homeopathic Medical
Congress, session of 1891.
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A TEXT-BOOK OF GYNECOLOGY.
that the rapid strides of gynecology will soon define the types
of epilepsy wherein the operation will prove useful. When
actual disease of the appendages is demonstrable there is even
now a pretty general consensus of opinion that an operation is
indicated, especially if the menstrual exacerbations are marked.
Unfortunately it is often impossible to demonstrate actual disease
within the ovary without the aid of the microscope. The patho-
logical findings in epilepsy have been most variable. Different
investigators working along this line have come to as many
different conclusions. One has declared that in epilepsy the
weight of the brain is increased (Echeverria); another that its
weight is diminished (Meynert); and still another that there
exists an unequal proportion of the two hemispheres. Again,
dilatation of the vessels of the superior portion of the cord;
aneurysm and atheroma of the blood-vessels; sclerosis of the
cornu-Ammonis; anemia of the brain; an increased quantity of
the cerebro-spinal fluid; tumors and thickening of the meninges
of the brain; great redness and vascular tension in the fourth
ventricle (Schroeder van der Kolk); alteration of the pineal
gland; abnormal thickness and abnormal thinness of the cranial
bones; and fatty degeneration of some portion of the medulla
oblongata, are some of the many changes found post-mortem in
epileptics. Indeed, the changes recorded by pathologists are so
various that it is utterly impossible to construct an explanation
of the paroxysms upon a pathological basis.
There yet remains a by no means insignificant number of
cases in which neither the foregoing nor any other lesion, dis-
coverable even by the closest scrutiny, exists. In all nervous
affections characterized by paroxysms, attacks or fits of any
kind, the essential feature is, according to Brown-Sequard, a
morbid increase of the reflex excitability, the symptomatic
manifestations depending upon "what nerve cells are altered in
their vital properties." It has been pretty conclusively proved
that there is no constant seat of epilepsy; and it is not unreason-
able to believe that irritation in any peripheral part of the
nervous system may so irritate the cells at the base of the brain,
or the upper part of the cord, or both, that in time their nutri-
tion will become so altered as to create a morbid excitability.
THE HYSTERO-NEUROSES: HYSTERIA.
219
This is about the extent of our actual knowledge of epilepsy.
The changes in these cells are more dynamical than physical,
and the most powerful microscope has not yet revealed the
difference between those which are perfectly normal and those
which possess great morbid reflex power. (Brown-Sequard.)
Both clinical observation and experimental research tend to
show that these cells are located chiefly in the base of the brain.
The fact that the early manifestations of an attack of epilepsy
may be in very different parts of the body shows that their
location must be variable. If this observation suggests any-
thing it suggests the possibility of the most diverse forms of
peripheral irritation exciting epilepsy. This theory is in perfect
harmony with clinical observation. Literature contains in-
numerable instances of epilepsies caused by injuries to nerves
and organs distant from the brain.* I submit that in the light
of the array of clinical evidence now in our possession we are
justified in believing that irritation having its origin in the uterus
or the ovaries may, under certain circumstances, excite epilepsy;
and if we can detect such irritation and remove it, we may cure
the disease, providing irreparable damage has not been done to
the nerve centers. It is in support of this proposition that I re-
cord three clinical cases of my own. With the exception of the
first, none has been absolutely cured, but all have been immeas-
urably benefited. The time that has elapsed since the opera-
tions were performed in the several cases-two, four and seven
years-tends to show that the benefit is permanent.
Illustrative Cases.
CASE XX.-Epilepsy Mitior (petit mal ) Cured by Operating upon the Cervix and
Perineum. Mrs. C., æt. 26. Patient of Dr. E. F. Chase of Dexter, Michigan.
Married, and at the time of consulting me was the mother of two children. For
nearly eighteen months before coming to me she suffered from frequent attacks of
petit mal, always worse during the menstrual week. While engaged in conversation
she would suddenly pause in the most unaccountable manner in the middle of a
*v. Medical Record, July 21, 1890, for a case of reflex epilepsy cured by the removal
of a shoe-button from the left cavity of the nose; and New Orleans Medical and Sur-
gical Journal, October, 1889, for a case of petit mal, with concomitant asthma, in
which all symptoms were relieved by curing septal and turbinal hypertrophies, seated
far back.
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A TEXT-BOOK OF GYNECOLOGY.
sentence, the expression becoming perfectly blank; in a few seconds she would again
resume conversation, being conscious, however, that there had been a break in the
continuity of thought. Automatic action was also interrupted, and if walking she
would stop during the unconscious interval. She suffered much from a dull, heavy,
occipital headache with depression and great irritability. Her memory was more or
less impaired. Family history good. There was menorrhagia with dysmenorrhea
and leucorrhea.
Upon making a local examination I found a stellate cervical laceration, with subin-
volution and much tenderness. The perineum was torn down to the sphincter mus-
cle and the vaginal walls were likewise subinvoluted. I repaired the cervix and
perineum in the usual manner, after which the attacks of petit mal became less fre-
quent. Six months after the operation she reported herself a “new woman. Six
years after there had been no recurrence of the symptoms, notwithstanding the fact
that since the operation she had given birth to a third child.
CASE XXI.-Epilepsy of Six Years Standing Greatly Relieved by Removal of
the Appendages.—Miss J. D., æt. 23, Harrisville, Pa. Mother died of phthisis three
years ago, at the age of fifty. Father living, æt. 75. When nine years of age she
sustained a fall, striking on her left side, since which time there has been great sensi-
tiveness in the left ovarian region. Menstruation became regular at fourteen, and
although unusually nervous, nothing like an epileptic paroxysm made its appearance
until she was seventeen years of age. These attacks gradually increased in frequency,
so that during the three years preceding the operation she had on an average two or
three every night.
October 23, 1887, through the instrumentality of Dr. M. B. Snyder, she came to
our college clinic for relief. At this time her general health was fairly good; she
slept and ate well, and the digestive and urinary functions were normal. If it had
not been for the nervous paroxysms and the pain in the left side, she would have con-
sidered herself quite well. The attacks, usually nocturnal, were preceded by an
ovarian aura. There was a feeling as if the left ovary were grasped and squeezed.
This peculiar sensation extended up the left side of the body into the head, when
she was compelled to sit down and lost entire control of herself so far as voluntary
motions were concerned, but never became unconscious. If the attacks were
unusually severe there was pain in the vertex; they were somewhat more frequent
just before and during menstruation. The tongue had never been bitten, nor was
there any history of an epileptic cry. The patient brought with her a bottle of
bromid, and was profoundly under its influence; while modifying the severity of the
attacks the drug had no perceptible effect upon their frequency. The memory, much
to the patient's horror, was becoming seriously involved, and the besotted condition
of the face, together with a peculiar, anxious look, indicated conclusively the natural
tendency of the disease. A local examination showed both ovaries to be enlarged,
and exceedingly sensitive. Pressure upon the left ovarian region would precipitate a
convulsive attack, during which the limbs would become straightened and rigid, the
hands clenched, the teeth set, and the eyes rolled back. The face would become
more or less congested, but there was no frothing at the mouth. The attack would
not last over thirty seconds. Unfortunately no opportunity presented itself to resort
to pressure in an attack not thus induced.
The case seemed one eminently appropriate for operative interference. The trouble
THE HYSTERO-NEUROSES: HYSTERIA.
221
dated from an injury, and there could be no doubt that an ovarian lesion, and a serious
one, existed. It is true, the paroxysms were not particularly aggravated during the men-
strual period; yet a test, to my mind far more conclusive in demonstrating the con-
nection existing between the ovarian lesion and the paroxysms, was present, namely,
the ease with which one could be induced by ovarian pressure. The patient was for
a month placed under the indicated remedy and proper local treatment, including
galvanization, but only grew worse. She was very impatient to have an operation
performed, having come several hundred miles for that purpose. With more indefinite
local lesions I should have declined to operate without further efforts with constitu-
tional and local measures. Under the circumstances, however, I performed double
salpingo-oophorectomy on November 21st, 1887, in the usual manner. Both ovaries
were about three times their normal size, and both full of distended follicles, the
result of cystic degeneration. Hydrosalpinx was likewise present on both sides.
Why, with the right ovary and tube implicated in the pathological changes quite
as much as the left, the pain should be entirely confined to the left side, is a problem
for our neuro-pathologists to solve. It is hardly explicable upon an anatomical basis.
A change for the better seemed to come over the patient almost as soon as she
regained consciousness. Her face was brighter, and that terribly besotted look had
disappeared. There was hardly an elevation of the temperature until the seventh
day, when it became slightly increased, owing to delay in removing the abdominal
dressing. No paroxysms took place until the third day after the operation; none
again for a week, after which they recurred at lengthened intervals until December
29th, when she left the hospital, the longest interval being 14 days.
Improvement, in every respect, was of the most decided character. The day be-
fore starting upon her long journey home, and unbeknown to the hospital attachés,
she went out upon a prolonged shopping expedition and became very weary. That
night she had a paroxysm, and upon her return home had two or three in frequent
succession. Through a mutual acquaintance I learn that the attacks now rarely
recur, are almost imperceptible when they do recur, and that she is supporting herself
by hard work.
CASE XXII.—Epilepsy of Fourteen Years Duration Greatly Relieved by Re-
moval of Appendages.—I shall record this case in the language of my former assistant,
Dr. V. D. Garwood, whose patient she was: "The patient, Miss R., æt. 45, is a
woman of unusual intelligence; born of German parents. She lived in a quiet
borough, of pronounced religious influence, inheriting, especially from her father,
who ranked high as a scientist and musician, a sensitive, nervous system, and
was pressed by him to the furthest limit in her education; on the other hand she
was brought up in the Medean and Persian routine of German housewifery. When
dysmenorrhea appeared it was regarded as too trivial for treatment, until epilepsy
developed.
"As a child she was healthy until eleven, when she had scarlet fever, and for
years after was subject to enuresis. Pleurisy followed some time after scarlet fever.
At seventeen, eczema upon the hands appeared, lasting about a year, which was
cured by outward application.
"Between eighteen and twenty years of age she suffered frequently from asthma,
which appeared every July. While engaged in teaching a year or two later a violent
attack of acute pain and cramps in the stomach occurred, followed by a jaundiced
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A TEXT-BOOK OF GYNECOLOGY.
condition. This attack was supposed by the physicians in attendance to be due to a
round perforating ulcer of the stomach.
"From that time until twenty-nine years of age she seemed to be in fair health,
with the exception of dysmenorrhea, to which no attention was paid. The first
spasm—a very slight one-occurred in August, 1875. These continued during the
fall, and were accompanied by an unpleasant noise in the head. She did not fall or
lose consciousness; the slighest sound was increased to an unendurable noise in her
head. Her attendants approached her on tip-toe to give her a drink or to fan her.
Toward Christmas of that year the unconscious attacks began at night, with the
petit mal during the day.
"At this stage of her trouble the most eminent physicians of Philadelphia were
consulted-Drs. Weir Mitchell, Goodell, and others. After some time the mania
epileptica developed; this, however, after the discontinuance of the bromids. In
April, 1885, she had an attack of acute rheumatism, in which hyperpyrexia was
marked. After this there was complete exemption for six months from the nervous
attacks, but overwork and intense strain upon the emotions brought them on again
with renewed violence.
“She came under my care in August, 1888. For the preceding year one week of
each month-her menstrual week-had been a perfect blank to her, owing to the
frequency of the paroxysms. She had often bitten her tongue and had injured her-
self severely by falling. Observing that the periodicity of the attacks was that of the
catamenia, I consulted Dr. J. C. Wood, who, in May, 1889, performed salpingo-
oöphorectomy. From that time until August there were no spasms. In October
there was a severe outbreak, but since that time until January, 1891, only slight at-
tacks every two months, with excellent health in the intervals. She has returned to
society and to her literary work. Her memory is being rapidly restored, and she en-
joys life as never before since her illness."*
In this case I found great tenderness of the ovaries but no
perceptible enlargement. After removal they were examined
by Prof. Heneage Gibbes, the pathologist of the University, who
reported hyaline degeneration. Certainly if such a thing as a
"menstrual epilepsy" exists, this was a case, and under the
circumstances I had no hesitancy in removing the appendages.
She came to me after passing through the hands of some of the
ablest physicians of both schools, and I knew that all ordinary
resources had been exhausted.†
*This patient's improved condition remained permanent for two years, when she
had a paroxysm in an out-house and died from strangulation.
† I have succeeded, in a case referred to me by Prof. D. A. MacLachlan, in reducing
the number of paroxysms from two or three a month to one in six months, simply by
divulsing the cervix and the rectum. There was marked obstructive dysmenorrhea
and obstinate constipation, both of which were entirely cured by the operation. The
epilepsy was of twenty years duration.
THE HYSTERO-NEUROSES: HYSTERIA.
223
The extent of the disease is hardly a reliable criterion on
which to base the necessity of operative interference, for we
know that a slight amount of disease will in one woman pro-
duce serious reflex symptoms, whereas, in another, most ex-
tensive lesions will produce no disturbance whatever. It is
necessary, therefore, under all circumstances in dealing with
neuroses, to recognize types of constitution as well as the char-
acter of local lesions. Indeed, in descending the pathological
scale, a point may be reached where, instead of actual disease,
there is simply functional disturbance which must be recognized
as a causative factor. I believe, however, that we are rarely
justified in removing the appendages unless there is pretty con-
clusive evidence of local disease. If such evidence be forth-
coming; if the fits are intimately associated with the menstrual
function; if the aura starts from the ovarian region; if there
are no evidences of serious disease of the nerve-centers; if the
health and mind are failing and the patient is rapidly approaching
a state of chronic invalidism or insanity; and, above all, if all
ordinary measures have been exhausted and internal medication
faithfully tried, I believe that the gynecologist is justified in
resorting to any reasonable measure promising some hope of
relief.
THE HYSTERICAL PAROXYSM.
A dissertation devoted to the hystero-neuroses and hysteria
would be incomplete without a brief description of the hysterical
paroxysm. However, were all of its manifold variations included
in this description another chapter would be necessary. I shall
therefore refer to the most salient features only.
An aura starting from the affected ovary frequently precedes
the attack. In the milder forms there is accelerated, irregular, and
often interrupted respiration. Spasms of the extremities, rhyth-
mical in character, accompany the perverted respiration. In a
few minutes the attack ceases, but others may follow in rapid
succession. Consciousness is rarely lost, though in the more
severe forms the loss of consciousness may be profound. Dis-
tortion and fixation of the trunk and extremities are caused by
the tetanic convulsions. The respiration becomes slow and ster-
torous, and there is frothing at the mouth. The bowels are fre-
quently greatly distended with gas. These symptoms, together
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A TEXT-BOOK OF GYNECOLOGY.
with the alternate tonic and clonic character of the convulsions,
have given rise to the term hystero-epilepsy. Before and after
the attacks there is often hemianesthesia and hyperesthesia.
Relaxation succeeds tetanic muscular contraction, and this is
followed in due time by exaggerated muscular phenomena.
Emotional symptoms soon supervene. Anger, resentment, joy,
grief, and apprehension are alternately depicted on the counten-
ance. Lascivious manifestations are not infrequent. There may
be hallucinations, during which the patient sees all sorts of
disagreeable objects and things. Then comes contrition, and
after it, recovery.
Treatment. The physician must assume absolute control
of the room and its inmates. Sympathizing and excited friends
should be excluded. Slight hysterical seizures of an emotional
character can often be controlled by the indicated remedy, or
by inhalations of ammonia, or of nitrite of amyl. When the par-
oxysm is fully developed more radical measures are necessary.
Most authorities recommend douching the head and face with
cold water. This is a successful method of treatment, but a
difficult one to apply without wetting the clothing. A few tea-
spoonfuls of water poured into the mouth or nostrils will often
accomplish the same purpose, and should be first tried. It acts
by stimulating the respiratory centers. Dr. Hare recommends
closing the nostrils and mouth for fifteen or twenty seconds with
a towel. Chloroform or ether inhalation is very effective, and one
of the best methods of controlling an attack. Ice-water injected
into the rectum may be tried. Cruveilhier and Ashwell recom-
mend that cold water be injected into the stomach. Cutaneous
faradization has been found useful. It is accomplished by
placing the two electrodes anywhere from the neck to the
hand, or on the two hands. Finally, Gowers * uses, when all
other measures have failed, a hypodermic injection of a twelfth
or sixteenth of a grain of apomorphia with invariable success.
As soon as nausea is excited the paroxysm ceases, and the patient
regains consciousness immediately upon vomiting, which occurs
in six or eight minutes after the injection.
Pressure over the region of the ovaries, according to the
* "Diseases of the Nervous System," p. 1329.
THE HYSTERO-NEUROSES: HYSTERIA.
225
method of Charcot,* is a simple, harmless, and often a most
effectual procedure. It is accomplished by placing the patient
in a horizontal position on the floor or mattress and pressing the
closed hand or fist into one or both iliac fossæ. Much force is
at first necessary to overcome the contraction of the abdominal
muscles. If successful, the patient soon makes numerous and
noisy attempts to swallow, when consciousness returns. The
phenomena of the seizure disappear in from two to four minutes.
Therapeutics.
Moschus.-Constriction of the chest, frequent swooning,
great anguish with fear of death; HYSTERIA SIMULATING TETANIC
SPASMS; globus hystericus; great desire for beer or brandy.
Chamomilla.-Irritable, peevish, impatient; great tendency to
quarrel, to speak in an obstreperous manner; moaning and
wailing during sleep.
Hyoscyamus. Jerking and twitching in the spasms; convul-
sions resemble epilepsy; much silly laughter and foolish action;
she is disposed to uncover herself and go naked.
Caulophyllum.—HYSTERICAL CONVULSIONS DURING DYSMEN-
ORRHEA; hysteria in anemic and greatly debilitated patients;
spasmodic, intermittent pains in the bladder, stomach, groins,
chest and limbs.
Platina.-Self-exaltation and contempt for others; a strange
titillating sensation extending from the genital organs up into the
abdomen; spasms, with wild shrieks; horrifying thoughts;
menses in excess, dark and thick.
Nux Moschata.-Frequent and sudden change of mental
symptoms; excessive tendency to laughter; enormous distention
of abdomen after meals; EXCESSIVE DRYNESS OF MOUTH AFTER
SLEEPING.
Lachesis.-Sensation as if a lump were rising in the throat;
CANNOT BEAR THE LEAST PRESSURE EXTERNALLY ON ANY PART OF
THE BODY; AGGRAVATION AFTER SLEEPING.
Consult:-ANACARDIUM, AURUM, asafetida, GELSEMIUM, cactus
grand., lilium tigr., stramonium, ZINCUM, tarantula, valeriana.
* "New Sydenham Society of Charcot's Lectures," p. 27
15
CHAPTER XVI.
MENSTRUATION AND ITS DISORDERS.
PHYSIOLOGY OF MENSTRUATION; AMENORRHEA
General Considerations.-The anomalies of menstruation
cannot be intelligently studied without a familiarity with its
physiology. As to the cause of menstruation there is much
that is yet uncertain; the phenomena belonging to the function
are, however, well known; and, from a practical standpoint, it
is these which most concern the physician.
Definition. Menstruation may be defined as a periodical
discharge of blood from the uterine cavity, recurring at regular
intervals between puberty and the menopause, except when
physiologically interrupted by pregnancy and lactation. Puberty
begins in this climate at the average age of thirteen, and climac-
teric changes are usually inaugurated at about forty-four. The
age of puberty is influenced by climate, habits, idiosyncrasies
and disease. It occurs earlier in warm than in cold climates,
and in large cities than in rural regions. * It is delayed in cer-
tain families until the age of sixteen, seventeen or even twenty
years, without any perceptible ill-effect; and it is frequently de-
layed for an indefinite time by some constitutional bias, notably
tuberculosis.
The symptoms of approaching puberty are very characteristic.
The habits of girlhood are discarded for those of retiring
womanhood, the figure develops, and the breasts enlarge;
coincident with these changes, hair appears upon the mons
Veneris.
The symptoms of perfectly normal menstruation are objective
rather than subjective. Nevertheless, there are few girls or
* Lutaud (Bulletins et mémoirs de la Société obstétricale et gynécologique, Paris,
December, 1890), reports the case of a girl who began to menstruate at seven years and
two months. The patient was well formed and healthy.
226
MENSTRUATION AND ITS DISORDERS.
227
women who do not suffer just before the advent of the flow
from a feeling of uneasiness or weight in the pelvic organs, and
frequently there is an unpleasant sense of fulness in the breasts.
These symptoms are particularly marked at the first menstrual
period, and are often accompanied with decided nervous phe-
nomena. Occasionally the first knowledge of the approaching
period is the presence of the flow.
A normal period continues from two to eight days, and the
quantity of blood lost varies from two to nine ounces (three to
twelve napkins). Either extreme may be perfectly normal,
depending upon the temperament and habits of the menstru-
ating woman. The average duration is about four days, and the
average quantity of blood lost, five ounces. During the inva-
sion the discharge is pale; during its persistence it becomes
darker, is non-coagulable, and consists of red and white blood
corpuscles, granular corpuscles, and mucous globules com-
mingled with epithelium from the uterine, cervical, and vaginal
cavities; during its decline it again becomes pale. Unless the
flow is excessive there is no clotting, for the vaginal secretion
preserves its fluidity.
Theories.-The ovarian theory of menstruation, advanced and
advocated by Costé, Gendren, Bischoff, Negrier, and Pflüger,
has long been, and still remains, the classical one. According
to this theory, ovulation and ovarian irritation are responsible
for menstruation. When oophorectomy became a common
operation, it was observed that menstruation sometimes per-
sisted even after the ovaries were removed; and that the func-
tion was more surely, although not invariably, abrogated if the
Fallopian tubes were removed with them. Lawson Tait, who
was the first to observe this fact, promulgated the so-called
Fallopian theory of menstruation. He maintains that the func-
tion of menstruation is not ruled by the ovaries, and presents
the following reasons why he believes that the starting point is
the Fallopian tubes :—
(1) Pain when the tubes are occluded; (2) the first appear-
ance of menstrual fluid in the tubes; (3) the continuance of
menstruation after the removal of the ovaries; (4) the arrest of
menstruation after the removal of the tubes.
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A TEXT-BOOK OF GYNECOLOGY.
As counter evidence to the Fallopian theory and in support
of the ovarian, the following observations are presented :—*
(1) When the ovaries are congenitally absent menstruation is
also wanting; (2) when the ovaries are removed early in life the
same result is apparent; (3) when the ovaries are removed after
puberty menstruation generally ceases; (4) all the secondary
sexual characters of the female are dominated by the ovary,
and menstruation is one of these.
The arguments set forth to substantiate these two theories of
menstruation—the Fallopian and the ovarian—are based upon
certain phenomena which are by no means invariable. It may
be said that, while menstruation does sometimes persist after
the removal of the ovaries without the tubes, this is only
exceptionally the case; and it cannot be maintained that the
function always ceases after the ovaries and tubes are both
removed, for a number of authentic cases are now on record
in which both appendages have been removed without accom-
plishing this end. That the first appearance of the menstrual
blood in the human female is always in the tubes is hardly sus-
ceptible of proof.
On the other hand it must be admitted that menstruation
occurs at a period of life when ovulation is most active; but
that there is a causal relation existing between the menstrual
flow and the escape of the ovule, while probable, has not yet
been conclusively proved.
A still more modern theory is that of Campbell.† Campbell
believes that the menstrual rhythm is initiated by a nervous
rhythm dependent upon nervous structures. "Just as there is a
rhythmically pulsating respiratory and cardiac center, so there
is a rhythmically pulsating sexual center which furnishes fibers
both to the ovaries and to the uterus, those of the latter passing,
for the most part, along the Fallopian tubes, but some few to
the uterus directly."
Campbell further believes that ovulation is an essential, though
not an indispensable, factor of the menstrual rhythm. This
hypothesis will at least explain the following facts as set forth :—
* London Lancet, December, 1888.
† Annual of Universal Medical Sciences, 1890.
MENSTRUATION AND ITS DISORDERS.
229
(1) The periodic flow sometimes continues after the removal
of the ovaries; (2) the function is generally abrogated by the
removal of the tubes; (3) occasionally it continues after both
the ovaries and tubes have been removed, just as a reflex
epilepsy sometimes continues after the source of irritation has
been removed. * Neither is there a general consensus of opin-
ion regarding the source of the hemorrhage, and the changes
which the endometrium undergoes. J. Bland Sutton † has
made a series of observations in the quadrumana, and has also
examined the uteri of some young women who died during
menstruation. From these observations Sutton is led to believe
that the disintegration of the mucous membrane is limited to
the superficial and glandular epithelium, and that the mucous
membrane of the Fallopian tubes remains unaltered.
Dr. Arthur W. Johnstone affirms “that the functions of the
ovary and the uterus are separate and distinct, and that the
endometrium is the real organ of menstruation." Dr. John-
stone's investigations go to prove that the loss of substance in
the menstruating uterus is limited to the epithelial lining of the
mucous membrane.
Kundrat and Engelmann also believe that only the superficial
layers of mucous membrane are removed.
In marked contrast to the foregoing views are those of Dr.
John Williams,‡ of London, who maintains that "uterine con-
traction drives the blood from the muscular walls into the
mucous membrane; the vessels of this membrane, having
undergone fatty degeneration, give way, and extravasation of
blood results. This extravasation takes place always near the
surface, for in that situation the degenerative changes have most
advanced. The rush of blood into the vessels of the mucous
membrane expels the contents of the glands, together with the
greater part of their lining epithelium.
When
* The still more recent observations of Robinson are in harmony with this theory.
Robinson believes that menstruation is inaugurated by tubal motion due to ganglia
situated in the uterine walls and along the tubes, which are intimately connected
with the ovaries.-New York Medical Journal, January, 1891.
† Brit. Gynec. Journal, 1886.
Obstetric Journal, London.
230
A TEXT-BOOK OF GYNECOLOGY.
hemorrhage has taken place into the membrane it undergoes a
rapid disintegration, and becomes entirely removed." Williams
believes that a new mucous membrane is formed from the
muscular wall of the organ. In the light of present data this
is hardly probable.
Leopold denies the existence of fatty degeneration, and
believes that the bleeding is due to the peculiar arrangement of
the blood-vessels in the endometrium. There exists, according
to this author, a disproportion between the arterioles that supply
the capillaries of the uterus, and the veins that receive the blood
-the arterioles being relatively larger; as a result a sudden
afflux of blood to the uterus is not carried off by the veins and
the capillaries rupture. In the process of disintegration only
the superficial layer of the mucous membrane is removed.
Möricke, basing his observations upon curettings from living
menstruating women, asserts that "during menstruation the
mucous membrane disappears neither partially nor fully."
It will be seen by the foregoing that much pertaining to the
physiology of menstruation is as yet unsettled. I have deemed
it best to present in a condensed form the more prominent
theories. I shall not venture an opinion of my own, further
than to add that Campbell's theory as regards the cause of the
periodical flow of blood termed menstruation, and Leopold's
theory as regards the changes which the uterine mucous mem-
brane undergoes, as the result of this flow, seem to me the most
reasonable.
AMENORRHEA.
The term amenorrhea signifies an absence or stoppage of the
menstrual discharge, due to causes other than physiological.
It may be primary (emansio-mensium) or secondary suppressio-
mensium). In both of these forms there is non-secretion. Reten-
tion of the flow is also classified under the head of amenorrhea,
though the causes responsible for the absence of the discharge
are radically different from those giving rise to the primary and
secondary forms. Amenorrhea is physiological during preg-
nancy and lactation.
Primary Amenorrhea. (Emansio-mensium).—In the primary
form of amenorrhea menstruation has never occurred and
MENSTRUATION AND ITS DISORDERS.
231
puberty, for some reason, is delayed. The causes for such
delay are variable and must be carefully sought for. Probably
some form of constitutional bias, anemia, tuberculosis, scrofulosis,
or rickets, is oftener responsible for it than anything else. Such
being the case the patient's vitality is conserved by the amenor-
rhea. Again the menstrual function may be held in abeyance
by misdirected mental effort and insufficient exercise. Con-
genital defects involving the uterus, ovaries, Fallopian tubes, or
indeed, any of the sexual organs, are not infrequently responsible
for the non-appearance of the menses.
The symptoms of primary amenorrhea are those of delayed
puberty. The changes incident to normal puberty are wanting:
the breasts do not enlarge, the figure remains undeveloped, and
no hair appears upon the mons Veneris. Molimina may or may
not be present: if present many of the symptoms of menstruation
occur, minus the flow; if absent, and the cause is due to one
of the enumerated constitutional disorders, the symptoms of the
latter will stand out prominently. Let it be remembered that
in these instances the amenorrhea is the effect and not the cause
of the constitutional malady.
The delay of the function not infrequently gives rise to nervous
phenomena, especially when there is an effort on the part of the
system, as indicated by the molimina, to establish it. Hysteria
often occurs, and the nervous perturbation may result in chorea.
Neuralgia is not an uncommon symptom, especially if anemia
or chlorosis is marked.
The diagnosis of primary amenorrhea is not difficult. It ought
not to be mistaken for physiological amenorrhea due to preg-
nancy, and yet such mistakes have been made. In primary
amenorrhea the evidences of delayed puberty—the diminished
size of the uterus, the undeveloped mammæ and figure-and
the absence of abdominal tumor, all argue against pregnancy.
It must not be forgotten that conception is possible before
menstruation: from a practical as well as a medico-legal stand-
point this fact is important.
Secondary Amenorrhea. (Suppressio-mensium).—In secon-
dary amenorrhea the menstrual function has, for a longer or
shorter period, existed, but owing to some cause or causes it
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A TEXT-BOOK OF GYNECOLOGY.
has become suppressed. In acute diseases-phthisis, anemia,
and chlorosis-the suppression is not undesirable, for by means
of it the patient's strength is conserved. Indeed, menstruation
should not occur with an anemia at all marked; if it does, and
the flow is profuse, the physician is justified in suspecting that
the depravity of the blood is secondary to the menstrual excess.
In such cases an effort should be made to induce amenorrhea,
either partial or complete, by directing attention to the endome-
trium, for, in many instances, the latter will be found abnormal.
Wylie observes that if amenorrhea occurs during the period of
development of the sexual organs their growth is often perma-
nently affected by it. The inflammatory diseases of the pelvis
may likewise produce amenorrhea by leaving in their train
lesions of the ovaries and tubes; oftener, however, such lesions
result in menorrhagia.
There are certain women, healthy in all other respects, who
suffer from suppression upon the least irregularity. Change of
climate or altitude, a sea voyage, or the slightest exposure,
is quite sufficient to induce amenorrhea. Usually it is
only temporary, and in due time the menstrual equilibrium
is restored; occasionally the system becomes so profoundly
impressed by the suppression that the amenorrhea remains per-
manently. Those who have to deal with immigrants coming to
this country state that amenorrhea frequently results from the
sea voyage and climatic changes combined.
The symptoms of secondary amenorrhea depend in no small
degree upon the suddenness of the suppression. In acute sup-
pression there is marked disturbance of the nervous and vascular
systems, manifesting itself in increased arterial tension, palpita-
tion of the heart, headache, neuralgic pains in various parts of
the body, and, not infrequently, hysteria. The local distress is
sometimes very great, the pain being sharp and darting, or
cramp-like. Occasionally the vascular excitement is preceded
by a chill, and the congestion induced may pass into serious
inflammation.
When amenorrhea is developed gradually, the symptoms are
less violent, though often of most serious import. Prostration,
lassitude, indigestion, constipation, and cardiac oppression, one
MENSTRUATION AND ITS DISORDERS.
233
or all, make their appearance in due time. The symptoms of
the disease which is responsible for the non-performance of the
function, anemia, phthisis, etc.,-force themselves upon the
attention of the physician. Under all circumstances pectoral
symptoms occurring in connection with amenorrhea demand
serious consideration.
Diagnosis.-This form of amenorrhea is easily mistaken for
pregnancy. The subjective symptoms are much the same in
both instances: nausea, vomiting, morning sickness, mammary
pains, etc., may result either from pathological or physiological
suppression. During early pregnancy the increased size of the
uterus is so slight as to make even the most deft diagnostician
uncertain regarding its contents. If the patient is untruthful,
and denies the possibility of pregnancy, time is the only abso-
lute test. After the third month the diagnosis can usually be
made with a fair degree of certainty.
Retention of the Flow.-Amenorrhea due to retention is
the result of some interference with the exit of the menstrual
discharge after it has been secreted. The cause of obstruction
may be congenital or acquired. An imperforate hymen is the
most frequent congenital cause, though the menses are sometimes
retained because of atresia of the vagina higher up. Usually,
however, when the vagina is congenitally absent the menstrual
function is held in abeyance.
The acquired causes oftener result from child-bearing, the
sequelæ of inflammation and sloughing. Operations upon the
cervix may also result in atresia. Tumors, polypi, flexures and
coagula may give rise to temporary retention.
Symptoms.-Retention of the menses may and usually does
give rise to much suffering. Attacks of pain recur at
regular intervals, with all the usual symptoms of menstruation,
except the flow. The pain is of a bearing-down character, com-
ing and going at variable intervals, and reaching its climax after
some hours duration. It then gradually subsides and finally dis-
appears to recur again at the next period. There is often
marked general disturbance during the paroxysm of suffering
which manifests itself in headache, increased arterial tension,
nausea and vomiting, pain in the back and limbs and nervous
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A TEXT-BOOK OF GYNECOLOGY.
phenomena of various kinds. Hysterical convulsions are not
infrequent, and even epilepsy may develop. In due time the
uterus becomes distended with the products of menstruation,
giving rise to a tumor in the hypogastric region.
Diagnosis.-The regular recurrence of molimina correspond-
ing to the menstrual cycle, and the gradual formation of a
tumor in the uterine region, together with the absence of the
menstrual discharge externally, will lead the physician to sus-
pect the nature of the case. The reflex symptoms of pregnancy
may be present, but a local examination will reveal the cause of
the difficulty. Such an examination may necessitate exploration
through both the rectum and bladder in order to determine the
presence or absence of the uterus and annexa.
The prognosis of amenorrhea depends entirely upon its cause.
Of the various constitutional ailments giving rise to it anemia
is the most amenable to treatment. If the result of acute
disease the system usually rights itself in due time. Tuberculosis
is, of course, always of serious import.
Of the anatomical causes imperforate hymen is the most easily
dealt with. Congenital absence of the uterus or ovaries makes
a cure impossible; if due to deficient development only, the prog-
nosis will depend upon the presence or absence of molimina.
When atresia of the vagina is responsible for the retention it is
possible, by surgical measures, to liberate the pent-up discharge
and to restore the canal to its normal condition; when it is con-
genitally absent, however, an attempt to form a vagina usually
results in failure.
THE TREATMENT OF AMENORRHEA.
Let it be remembered that amenorrhea is in many instances
but an expression of some systemic trouble toward which the
treatment should be directed. Anemia, chlorosis, nervous pros-
tration, tuberculosis, etc., are the real diseases of which the
amenorrhea may be but a symptom. The general and special
measures appropriate for these several diseases should be brought
into requisition. Under all circumstances fresh air, sunlight,
exercise, and good food are of the greatest utility. In short,
the several measures suggested in the chapter devoted to the
MENSTRUATION AND ITS DISORDERS.
235
General Treatment of Gynecological Diseases should be
applied.
In acute suppression an effort should be made to restore the
discharge, if this can be accomplished by measures which are
not injurious. Of first importance in accomplishing this end is
the indicated remedy. A hot foot or sitz bath is a most useful
adjuvant, as is also the hot douche. The latter is particularly
indicated if the evidences of local congestion are at all marked.
Failing with these several measures, after a few hours trial, it is
not best to attempt longer to restore the flow by the use of hot
water. The indicated remedy should, however, be continued
until the system is put right. The use of so-called emmena-
gogues is, under all circumstances, to be discouraged.
When amenorrhea or scanty menstruation is due to imperfect
development of the sexual organs, an effort should be made to
promote their development. This can be done in various ways,
but undoubtedly the most useful of all agents known at the
present time for accomplishing this end is electricity. The time
and technique of application are given in detail in the chapter
devoted to that subject. Patience and persistence are required
in using electricity for this purpose, but so long as nature con-
tinues to assert herself by exciting molimina, there is hope of
bringing on the flow. The introduction of the uterine sound
and the use of the galvanic stem pessary also stimulate the
uterus in a mechanical way. There can be no objection to the
careful use of the sound, but the intra-uterine stem is an instru-
ment always to be resorted to with the utmost caution.
Therapeutics.
Calcaria carb.-LEUCOPHLEGMASIA, with malnutrition and
disturbance of digestion; face pale and bloated, with blue rings
around the eyes; oppression of the chest tending to tuberculo-
sis; COLD HANDS AND COLD FEET; amenorrhea with anasarca
from working in water.
Ferrum.-ANEMIA; great nervousness and debility, with
FIERY REDNESS OF THE FACE ON THE LEAST EXCITEMENT; palpita-
tion of the heart; paleness of all the mucous membranes; diar-
236
A TEXT-BOOK OF GYNECOLOGY.
rhea, with undigested food; want of breath when moving or
ascending; pressure in the stomach and head.
Arsenicum.-White, waxy paleness of the face, and GREAT
DEBILITY; corrosive leucorrhea; frequent paroxysms of faint-
ing; painful lienteria, followed by much prostration.
Pulsatilla.-Especially useful at the age of puberty; sup-
pression from getting the feet wet; menstrual suppression com-
plicated with ophthalmia; hemicrania, with stitching pain in
face and teeth; painful lumps in the breast, extending to the
arms. (Guernsey.)
"When in girls of mild disposition puberty is unduly delayed, or the menstrual
function is defectively or irregularly performed; when they grow pale and languid,
and complain of headache, chilliness, and lassitude, pulsatilla (with or without fer-
rum) is a most excellent remedy."-Hughes.*
Kali carb.-Swelling of the EYELIDS; disposition to phle-
bitis; stiffness and pain in the small of the back; aggravation
of all symptoms at two or three o'clock in the morning.
Graphites. After pulsatilla; occasional show of menses,
which are very pale and very scanty, with abdominal pains and
pain in the limbs (Guernsey); GRAPHITES IS IN CLIMAXIS WHAT
PULSATILLA IS IN YOUTH (Lilienthal).
Sepia.-Yellow or greenish leucorrhea accompanied by much
itching of genital organs; amenorrhea at age of puberty or
later; PAINFUL SENSATION OF EMPTINESS AT PIT OF STOMACH ;
brown spots on chest and yellow saddle across bridge of nose.
Aconite.-Amenorrhea from taking cold or getting feet wet,
with congestion of the head and chest; suppression from fright
or vexation. Particularly useful in acute suppression in young
girls of sanguine temperament, and who lead a sedentary life.
Belladonna.-ACUTE SUPPRESSION WITH GREAT CONGESTION
* PULSATILLA LILIUM TIGRINUM. A Comparison.- Lilium, like Pulsatilla,
causes scanty menses, but the former has irritable mood, wants to die, and yet knows
not why; solicitude about health; absence of feeling in the head with amenorrhea;
longs for meat; diarrhea hurries her out of bed in the morning. Pulsatilla has gen-
tle, tearful mood; wants to die, but fears it; solicitude about health and salvation;
mania with amenorrhea; averse to meat; diarrhea after midnight. Remission, in
lilium, forenoon; in pulsatilla, midnight until noon (except diarrhea).—American
Journal of Homeopathic Materia Medica.
MENSTRUATION AND ITS DISORDERS.
237
OF THE FACE AND EYES AND THROBBING OF THE CAROTIDS;
intolerance of light or noise; bearing-down pains as if the con-
tents of the abdomen would issue through the vulva.
Secale corn. There is a continual, long lasting, forcing pain
in the uterus at the menstrual nisus; leucorrhea brownish and
offensive, resulting from weakness and venous congestion.
Sabadilla.--Menses are suppressed immediately on their
appearance, appearing again sooner or later, to be again sup-
pressed.
Apis mel.-Amenorrhea with bloated, waxy face; ovarian
irritation with stinging pains; cardiac distress.
Gelsemium.—Amenorrhea with a dull, heavy headache;
vertigo, with disturbed vision; darting, twitching, neuralgic
pains in the face.
Sulphur.-Great congestion of the pelvic organs and of the
head; coldness of the feet, or BURNING OF THE SOLES OF THE
FEET at night in bed; FLUSHES OF HEAT; hemorrhoids; chronic
inflammation of the eyelids and a general eruptive tendency.
Platina.-PAINFUL SENSITIVENESS and continual pressure in
region of mons Veneris and genital organs; frequent sensation
as if the menses would appear; amenorrhea with induration of
the uterus and co-existing ovarian irritation.
Aurum.-Amenorrhea with prolapsus uteri and MELANCHOLIA ;
thick, white leucorrhea, with burning and smarting of the vulva.
Opium.—Amenorrhea from fright; IRRESISTIBLE DROWSI-
NESS; great heaviness of the head with fainting on rising.
Dulcamara.-Menses suppressed by cold; mammary glands
engorged and hard; rash before menses.
Consult:-Causticum, mag. carb., cimicifuga, borax, mer-
curius, nux vom., xanthoxylum,* and zincum.
* Xanthoxylum in Amenorrhea.-A servant girl, during her catamenial period,
scrubbed the floor in naked feet. The flow ceased at once and there was no return.
At the end of six months she became emaciated, coughed terribly, with dirty, gray
expectoration, pale face, night sweats, etc. Thought she had consumption and gave
up work. Xanthoxylum brought on the menses in four days and she recovered
rapidly. It is now five months since, and she has menstruated regularly, and has so
far recovered her health that she has resumed her labor again.-DR. J. C. WILLIAMS,
U. S. Med. and Surg. Journal, October, 1871.
CHAPTER XVII.
MENSTRUATION AND ITS DISORDERS (Continued).
UTERINE HEMORRHAGE.
General Considerations.-Hemorrhage from the uterus
must be looked upon as different from hemorrhage proceeding
from any other organ of the body, for the uterus is normally
subjected to the greatest variations of vascularity. Again it is
necessary, in order to determine whether or not the menstrual
discharge is excessive in a given case, to consider the age
and idiosyncrasy of the patient, as well as the effect which
the discharge has upon the system. One woman can, with
impunity, lose an amount of blood which would be ruinous to
another.
•
Hemorrhage from the genital canal does not always proceed
from the uterus. It may have its origin in some lesion of the
vagina or the urethra, or indeed, a supposed uterine hemor-
rhage may come from the rectum. Women are sometimes
careless observers, and this fact should be borne in mind.
The term menorrhagia indicates the menstrual origin of the
hemorrhage and signifies excessive menstruation; the term
metrorrhagia signifies that the hemorrhage either occurs during,
or is prolonged into, the inter-menstrual period. This division is
convenient and in harmony with clinical observation. For the
purposes of study, however, it is more practicable to deal with
uterine hemorrhage per se, whether occurring at the menstrual or
the inter-menstrual period.
The various causes giving rise to abnormal hemorrhage from
the uterus may be classified as follows:
1. Constitutional,
(a) Hemorrhagic diathesis;
(b) Purpura;
(c) Tuberculosis;
(d) Bright's disease;
(e) Syphilis.
238
MENSTRUATION AND ITS DISORDERS.
239
2. General,.
3. Nervous, .
[ (a) Lactation;
(b) Pelvic congestion due to disorders of the heart,
liver, lungs, and stomach; sedentary habits
sexual excesses; and ovarian disturbances.
(c) Malaria;
(d) Lead poisoning;
(e) Pyrexial disorders.
{(8) Centric;
Reflex.
(a) Carcinoma;
4. Malignant lesions, .
{
(b) Sarcoma.
(a) Fibroma and polypi;
5. Non-malignant lesions, (b) Inflammatory;
6. Accidental, .
{
7. Pregnancy,
8. Climacteric.
(c) Subinvolution.
(a) Chronic uterine inversion;
(b) Hematocele ;
(c) Uterine displacements.
(a) Abortion;
(6) Placenta previa.
Constitutional Causes.-The various constitutional diseases
predispose to hemorrhage by inducing blood changes. In the
so called hemorrhagic diathesis, purpura, tuberculosis, Bright's
disease, and syphilis such changes have taken place, and the
blood readily passes through the lining membrane of the womb.
Long continued hemorrhage, the result of some local disease,
wil in due time so defibrinate the blood as to predispose to
hemorrhage from various channels of the body.
In dealing with the hemorrhagic diathesis it is not always pos-
sible to detect the constitutional bias. The victims of this
diathesis are known as "bleeders," and every, surgeon of ex-
perience has learned to dread them. In all other respects the
patient will seem to be perfectly well, but the slightest cut or
injury will bleed unduly. It is not surprising that the menstrual
discharge in these patients should be great enough to demand
attention.
Tuberculosis gives rise to amenorrhea oftener than to menor-
rhagia. Nevertheless tubercular patients do sometimes flow
excessively; and the disease may be precipitated by an exag-
gerated menstrual discharge which in time reduces the vitality
of the patient to such an extent as to make her an easy prey to
phthisis. In those cases of menorrhagia in which there is a
240
A TEXT-BOOK OF GYNECOLOGY.
predisposition to tuberculosis it should be the aim of the physi-
cian to conserve the patient's strength in every possible way.
In Bright's disease the concomitant symptoms,-albuminuria,
anasarca, edema, etc.,-will lead the examiner to look to the
kidneys for the cause of the mischief. I have more than once
met with uterine hemorrhage due to syphilis, which yielded
upon adopting an anti-syphilitic régime.
General Causes.-Of the general causes, excessive lactation,
malaria, lead poisoning, and the pyrexial disorders, all induce
hemorrhage by their degenerating influence upon the blood.
Menstruating women ought not to nurse their children, for
there are few constitutions strong enough to permit of the
double drain. This is especially true when there is a predispo-
sition to some of the foregoing diathetic troubles. Lactation
may also excite hemorrhage through reflex irritation.
Malaria undoubtedly predisposes to pelvic congestion, and it
may be impossible to control a uterine hemorrhage while the
patient remains in a malarious climate. It has been frequently
observed by English physicians that women who have lived for
any length of time in India are usually victims of menorrhagia.
Undoubtedly the tropical temperature, as well as the malaria, is
a potent factor in these cases.
The influence exerted by lead poisoning upon the uterus, and
its power to produce uterine hemorrhage, has not received
the attention from therapeutists commensurate with the import-
ance of the subject. I was first impressed with the homeopath-
icity of plumbum in menorrhagia by the experience of one of
the provers of the drug-a most intelligent lady practitioner—
whose menorrhagia dated from a proving made ten years
previously. Later clinical experience has confirmed this homeo-
pathicity in a number of instances. Benson Baker of Eng-
land.(Obstetrical Transactions, Vol. 1), and Paul of France, have
both called attention to this subject."
*
If parents who suffer from lead poisoning have children, we may
naturally expect that in their early years they will suffer from certain diseases analo-
gous to, or participating in, the general cachexia of lead poisoning; and if they did it
would not be unreasonable to consider these children as suffering from hereditary lead
poisoning.
From M. Paul's paper it appears that lead poisoning amongst
MENSTRUATION AND ITS DISORDERS.
241
Pelvic congestion due to the several conditions enumerated is a
prominent factor in causing and keeping up uterine hemorrhage.
If these causes continue active, the best directed treatment will
fail in its object. Luxurious and sedentary habits are pernicious
under any circumstances, but particularly so when there is a
tendency to flow excessively. Sexual excesses are equally harm-
ful, and it is sometimes exceedingly difficult to learn that such
excesses are practised. One of the most obstinate cases of
menorrhagia with which I have had to deal occurred in a girl
of twenty, who was a confirmed onanist. Many married women
are the victims of sexual excess or sexual irregularities, and a
temporary marital separation may be necessary before a cure
can be accomplished. If such excesses are associated with the
other enumerated causes, especially ovarian irritation, the case
is indeed complicated, and for its management no little tact and
skill will be required.
Nervous Causes.-That nervous influences may affect the
uterus and its functions for good or for evil has already been
shown. They may either emanate from the nerve centers, or
exert their influence in a reflex way. Undue emotional excite-
ment is the most frequent centric cause, and occurs oftener in
nervously prostrated patients who are subject to hysterical
manifestations. Spinal lesions-functional exhaustion, irrita-
He says:
women, and even amongst men, causes the death of the fetus in utero.
'The first time my attention was drawn to the subject was in the month of February,
1859, when a woman that worked at cleaning printers' type applied at the Hospital
Necker, suffering from menorrhagia. Coupled with this menorrhagia she also had
the symptoms of chronic lead poisoning. I learned from her that, previous to her
present employment, she had been delivered of three healthy children at full term,
still alive; but that since her employment as a type polisher she had suffered much
from ill health. Three months after taking to this employment she became tainted
with lead poisoning, and suffered from printers' colic. Four years later she had a
second attack of colic and suffered intense pain; shortly after she became pregnant
and was delivered of a dead child. Three years elapsed and she had a miscarriage
at the fifth month of her pregnancy. Besides these two cases of pregnancy she had
become eight other times pregnant, and each time, after a short suppression of the
menses, and the delay of two or three months, she miscarried, characterized by an
abundant menorrhagia, and accompanied with colicky pains at the time.'
•
M. Paul goes so far as to assert that if the father be tainted, the offspring may be
affected in utero, even though the mother has nothing to do with lead."-Baker.
16
242
A TEXT-BOOK OF GYNECOLOGY.
tion, etc.-may likewise transmit an unnatural stimulus to the
uterus.
Some of the reflex causes have already been referred to,
notably, ovarian and mammary irritation. Vesical and rectal
irritation, especially if tenesmus is marked, may act in the same.
way. Congestion of the rectum and the uterus are not infre-
quently associated: the latter resulting in menorrhagia and the
former in hemorrhoids. The effect of impressions conveyed
through any of the reflex channels probably would not be
sufficient to excite uterine hemorrhage were the uterus perfectly
normal; however, with the organ already the seat of disease
which has increased its vascularity, hemorrhage is easily excited
and maintained by irritation remote from the pelvis.
Malignant Lesions.-Under this head I have enumerated
carcinoma and sarcoma. In the later stages there is but little
difficulty in diagnosing their presence, but at the time of their
onset there may be the greatest difficulty in so doing. It is
important to remember that hemorrhage is by no means an
early symptom in all cases of malignancy, nor, indeed, in the
majority. According to the statistics of Dr. West it is the first
symptom only in about 44 per cent. of uterine cancers. When
an early symptom it is the result of congestion of the endo-
metrium; later on it is due to ulceration, which, by invading
the vascular structures, gives rise to a profuse and occasionally
fatal hemorrhage. The amount of blood lost depends in no
small measure upon the location of the disease; it is much more
profuse when the fundus is involved, and may or may not be
accompanied with pain.
When an unnatural loss of blood is the only symptom of
malignancy which presents itself the uncertainties are very
great, and the microscope may be the only means of making a
positive diagnosis. If the hemorrhage occurs at or near the so
called cancerous age, i. e., from forty to fifty, and if it recurs
during the intermenstrual period as well, the possibilities of
cancer are very great, and a careful investigation should be
made. In the later stages there usually exists with the hemor-
rhage an offensive leucorrhea, which, together with the cachexia,
make the presence of malignancy almost certain.
MENSTRUATION AND ITS DISORDERS.
243
The symptoms of sarcoma do not differ materially from those
of true carcinoma, except that in its formative period there is
often a free "rice-watery" discharge, containing grayish-white
shreds, which does not become offensive until after necrosis of
tissue sets in. Other than this there is little in the subjective
history which will enable the examiner to differentiate these
two forms of malignant disease. When cancer takes on the
form of cauliflower excrescence the hemorrhage may be induced
by sexual congress, walking, coughing, straining at stool, etc.
Non-malignant Lesions.-Hemorrhage resulting from the
several varieties of fibroid tumors varies greatly-the amount
depending in large measure upon the nature of the growth. It
is much more profuse in sub-mucous growths than in interstitial
or sub-peritoneal. The hemorrhage does not come from the
tumor itself but from the congested and hypertrophied mucous
membrane covering it. The unnatural flow is at first purely
menorrhagic, the discharge increasing from month to month
until finally it becomes almost persistent, and at times danger-
ously profuse. As the tumor increases in size pressure symp-
toms develop, and the patient usually detects its presence before
consulting her physician.
The amount of hemorrhage produced by the various types of
polypi is by no means governed by the size of these growths.
Sometimes a very small polypus will excite a most alarming
and even fatal hemorrhage; however, the presence of very large
ones may give rise to no inconvenience until after being forced
into the vagina. Mucous tumors are very much more liable to
excite hemorrhage than are fibrous, and, when small, they are
often detected with difficulty. One not larger than a hazelnut
will remain concealed within the uterine cavity until the cervix
is forcibly dilated. The hemorrhage proceeds in mucous.
polypi from the surface of the tumor as well as from the endo-
metrium.
Menorrhagia or metrorrhagia is a most common symptom in
endometritis and subinvolution. Congestion and congestive
hypertrophy cause an increase in the vascularity of the endo-
metrium and, not infrequently, it undergoes a “fungoid degen-
eration." These fungosities play an important part in the
244
A TEXT-BOOK OF GYNECOLOGY.
etiology of menorrhagia, and when the flow is at all intractable
they should be looked for. Subinvolution is a frequent sequel
of cervical lacerations.
Inflammatory deposits within the pelvis, with or without the
presence of pus, are often responsible for menorrhagia of a most
obstinate type which cannot be reached by the ordinary reme-
dies. Uterine congestion and endometritis are usually secondary
to pelvic inflammation. Involvement of the tubes and ovaries
is a most prolific cause of menorrhagia.
Accidental.-Uterine inversion is an accident which ought,
under all circumstances, to be recognized at the time of its occur-
rence. Strangely enough it sometimes remains undetected until
persistent hemorrhage leads to an exploration. In menor-
rhagia due to this cause the hemorrhage usually dates from
delivery, is severe at first but gradually becomes less; it recurs
at intervals corresponding to the menstrual cycle; it is attended
by a profuse and almost constant leucorrhea; and there will be
found on local examination a tumor which remains within the
vagina, or presents externally. There may be much difficulty
in differentiating an inverted fundus from a protruding polypus.*
It is hardly proper to designate hematocele as one of the
causes of uterine hemorrhage. Indeed, the cause of both the
hematocele and the excessive hemorrhage is usually one and
the same-a ruptured extra-uterine pregnancy cyst, some form
of general systemic depravity or some abnormality of the uterus,
peritoneum, ovaries, or tubes. In connection with the subject
of menorrhagia and metrorrhagia it is, however, important to
remember that a pelvic hematocele, either intra- or extra-
peritoneal, may be accompanied by an exaggerated flow of
blood externally. The constitutional symptom's resulting from
the hematocele are those of shock and collapse and will be
indicated by the countenance, pulse, respiration, etc.
The ordinary forms of uterine displacement give rise to menor-
rhagia by inducing a congestion of the uterus and its append-
ages. Hewett particularly emphasizes the importance of flex-
ions as causative factors; and while he may exaggerate their
* v. p. 109.
MENSTRUATION AND ITS DISORDERS.
245
importance the fact remains that in many instances menorrhagia
cannot be cured until the displacement is put right.
Pregnancy. In uterine hemorrhage proceeding from an abor-
tion the history of previous suppression will usually suggest the
cause; it must, however, be remembered that menstrual sup-
pression does not always follow upon conception. The hemor-
rhage accompanying abortion comes on gradually and the pains
recur at regular intervals; they are accompanied with shivering
and, frequently, nausea and vomiting; the flow of blood usually
ceases upon the expulsion of the ovum, and, if the uterus has
been thoroughly emptied, does not recur. If, on the contrary,
any of the membranes are left behind, the flow will continue
until the curette has been applied. The retained products of
conception may be carried for an indefinite length of time before
the real cause of the unnatural discharge is discovered. This
is oftener the case in early miscarriages, the existence of preg-
nancy not being suspected.
When placenta previa is responsible for the hemorrhage, the
circumstances are less confusing, for the placental separation
rarely takes place until the later stages of pregnancy, when the
patient knows that she is pregnant. A digital examination
will reveal the unnatural implantation of the placenta; in acci-
dental hemorrhage, i. e., hemorrhage resulting from the separa-
tion of a normally located placenta, a vaginal examination will
at least show that the placenta is not attached to the cervix.
Climacteric.—Women who have been in the habit of men-
struating profusely, and especially if full-blooded, frequently
lose more blood as the change of life approaches. The age of
the patient, together with her family history, will serve as a
guide in determining whether or not the increased loss is the
result of climacteric changes. I question, however, the entity
of a physiological climacteric hemorrhage, if such an expression
is permissible. The prevailing idea that hemorrhages at this
age are natural has resulted in much harm.
Conclusions. For guiding aphorisms in dealing with uterine
hemorrhage the reader is referred to page 76. The practice
of relying absolutely upon subjective symptoms and the indi-
cated remedy, when the loss of blood is at all persistent, is not
246
A TEXT-BOOK OF GYNECOLOGY.
only reprehensible but should be actionable as well. I fully
appreciate the value of internal medication in dealing with
menorrhagia and metrorrhagia, but, in at least a goodly propor-
tion of cases, something more is demanded. A careful examin-
ation, both local and general, must be instituted, the cause
sought for, and, if possible, removed. The physician should
bear in mind that he is dealing with a symptom of something
wrong elsewhere, and not a pathological entity. If the hemor-
rhage is an expression of malignancy the lesion may advance
beyond the operative stage before it is discovered; if, on the
other hand, it be due to causes other than malignancy the pro-
longed drain upon the system may result in anemia, general
anasarca, hysteria, neurasthenia, depraved nutrition with pro-
found emaciation, and death.
The prognosis of uterine hemorrhage will depend entirely
upon its cause. In dealing with anemia associated with menor-
rhagia it must not be forgotten that, unlike amenorrhea, uterine
hemorrhage is more often the cause than the result of the blood
depravity. When the causes are purely local gynecological
surgery has reached a degree of perfection which makes it pos-
sible to accomplish a cure, except in advanced malignancy, in
nearly every instance.
TREATMENT.
The treatment of uterine hemorrhage may be conveniently
´studied under the following heads: (a) General; (b) Conduct of
patient during the period; (c) Treatment of local causes; (d)
Immediate control of hemorrhage; and (e) Therapeutics.
The general treatment should include the various measures
recommended for amenorrhea. A prescribed diet is often of
the greatest utility: if the patient is plethoric and of sedentary
habits it should be restricted; if, on the other hand, her nutri-
tion is below par it should be generous. Out-door exercise is
to be recommended in all instances where counter indications
do not prevail; or if the hemorrhage is brought on by it, and
particularly if prostration is a marked symptom, all forms of
exercise may have to be proscribed. Fresh air and sunlight are,
however, curative agents that can in most instances be utilized,
even though the patient cannot go out-doors. All clothing
MENSTRUATION AND ITS DISORDERS.
247
+
should be suspended from the shoulders so as to avoid con-
stricting the waist, and crowding the abdominal organs into the
pelvis. Constipation is an important factor in keeping up pelvic
congestion and should be corrected; inactivity of the liver like-
wise obstructs the pelvic circulation, hence measures tending to
overcome hepatic sluggishness are to be instituted. If one or
more of the several constitutional causes exist, the treatment
most appropriate for such causes must be adopted. If the
patient reside in a malarious region a change of climate may be
necessary before a cure can be accomplished. In short, what-
ever be the cause of the unnatural discharge, our treatment
must be directed toward it.
During the period, and for a day or two previously to its onset,
the patient should exercise as little as possible. The recumbent
posture, and, if the hemorrhage is alarming, the recumbent
posture with the foot of the bed elevated, should be maintained.
Of first importance for the immediate control of the hemorrhage
is heat. The hot douche, ranging in temperature from 110° to
120°, is a therapeutic resource in uterine hemorrhage whose
value cannot be overestimated. When used for its immediate
effect, however, its thermic properties are indispensable. This
implies a temperature of not less than 110°, and the maximum
120° is still more useful. The proper method of administering
the douche is described in another place.*
The primary action of cold is to contract blood-vessels-hence
its usefulness in controlling hemorrhage. Unfortunately its
secondary action is that of dilatation, so that in most instances
heat is by far the better agent. Another advantage which heat
possesses over cold as a hemostatic, is that it does not shock.
the system as does the latter. Nevertheless, cold will some-
times succeed in promoting uterine contractions when heat fails,
and is, therefore, to be held in reserve. Indeed, the alternate
use of heat and cold will sometimes cause the uterus to contract
when either agent used alone is ineffectual. It may be applied
in the form of a vaginal douche, or by the aid of an ice-bag
within the vagina or over the pubis; or by cloths wrung from
* Chapter X.
248
A TEXT-BOOK OF GYNECOLOGY.
cold water and applied to the lower abdomen. An ice-bag
placed over the lower spine is sometimes most effectual. When
the evidences of shock and collapse are at all prominent cold
must be used with the utmost caution; if these symptoms obtain,
and the hot douche has failed to control the hemorrhage, other
measures about to be described are preferable.
Failing to control the loss of blood by the use of heat and
cold the tampon is indicated in all forms of uterine hemorrhage,
except post-partum hemorrhage after the fourth month. In
placenta previa and accidental hemorrhage it is indicated provided
the uterus has not expelled the fetus. The hemorrhage may
occur at any time during utero-gestation; after the fourth month,
however, if the fetus has been expelled, the uterus will hold
sufficient blood to make the use of the tampon dangerous.
Antiseptic cotton prepared and introduced according to the
directions given in Chapter X, is the best material for the con-
struction of tampons. In cases of emergency any material—
roller-bandage, silk handkerchief, tarred jute, etc.—may be used,
provided it is clean. Tamponnement of the vagina, to prove
effectual in controlling hemorrhage, must be thoroughly done, so
that there can be no leakage about or through the tampons.
One or two wads of cotton, loosely placed against the cervix,
are not only absolutely useless, but do more harm than good,
for their presence tends to excite hemorrhage. They should not
be retained longer than eight or ten hours when used for this
purpose, and their introduction should be preceded and followed
by an antiseptic douche. The cervical plug—tents or the Barnes
bag is hardly to be commended except in placenta previa or
when dilatation of the cervical canal is imperative. There is a
tendency to abandon the use of tents for dilating purposes, be-
cause of the danger of sepsis attending their use. If dilatation
is indicated the rapid method under ether is the preferable one.
Astringents are rarely necessary to supplement the action of the
tampon. Occasionally, however, passive hemorrhage will con-
tinue from the uterine cavity in spite of the foregoing methods.
The blood-vessels and capillaries may remain unaffected not-
withstanding the application of heat and cold, and the uterus
may not respond to ordinary stimuli: in rare instances of this
MENSTRUATION AND ITS DISORDERS.
249
kind astringents are useful. They must be applied directly to
the bleeding surface. Alum, tannin, hamamelis and iron, are
those most frequently used. Alum, in the form of a saturated
solution, may be cautiously injected into the uterine cavity pro-
viding the os is patulous. Any intra-uterine injection must
be administered with the utmost care: no force should be used
in its introduction and unless the cervical canal is sufficiently
open, a reflux catheter is necessary. In short, provision should
always be made for the ready exit of the fluid when thrown into
the uterine cavity. The fluid used should always be warm.
If the hemorrhage proceeds from the cervix or vagina the
alum solution can be advantageously used in a vaginal douche.
It is an excellent agent in controlling hemorrhage after cervical
FIG. 58.

G.TIEMANN & CO-
O
BOZEMAN'S REFLUX UTERINE CATHeter.
and plastic operations within the vagina, for it does not form
coagula to interfere with union as does iron and as other more
powerful astringents do.
Hamamelis (1: 20) may be used instead of the alum, and in
the same manner, if the hemorrhage is of a decidedly venous
character or the remedy is called for because of constitutional
symptoms.
Tannin and iron, to prove useful, must be concentrated, and
are best applied directly to the endometrium by means of an
applicator. Tannin is highly recommended by many authors,
but I believe that its action is more uncertain than that of iron,
and in all instances where the former is useful the latter will
prove more so.. The patient should be placed in the Sims pos-
ture, the cervix fixed, the coagula washed away with a bichlo-
rid solution (1:5000) and the chlorid of iron, diluted with
250
A TEXT-BOOK OF GYNECOLOGY.
twice its bulk of water, applied over the entire endometrium.
This heroic method should never be resorted to except when all
ordinary measures have failed, for coagula left within the uterine
cavity are always dangerous. Its use is only justified when the
patient's life is threatened by an otherwise uncontrollable hem-
orrhage; we then use it to avoid a great and pressing danger by
running the chance of a lesser one.
Treatment of Local Causes.-The treatment of the several local
causes, both malignant and non-malignant, is given in detail in
other chapters. A few general considerations are, however,
necessary at this time. Fibroid tumors may, and frequently do,
necessitate operative interference; uterine displacements are to
be corrected by appropriate measures; endometritis and subin-
volution should be attacked by proper local and internal treat-
ment-the local measures comprehending the intelligent use of
the curette and the reparation of cervical lacerations; finally,
the products of abortion, if they exist, should be sought for and
removed. In dealing with these various conditions the curette
is so frequently called for as to warrant a careful description of
the technique of its application.
The Application of the Curette.-The use of this instrument
for diagnostic purposes has already been referred to (v. Chapter
V). In its application for either diagnostic or curative purposes
certain precautions are necessary: it should never be used if
acute inflammation, either of the uterus or of the tissues about
the uterus, is present; it is to be resorted to with the utmost
caution if long-standing inflammatory deposits within the pelvis
exist; last, but not least, the greatest cleanliness should be
observed in its application. Since adopting the antiseptic precau-
tions of Leopold, whose method I learned from personal obser-
vation, I have never had to contend with a single unpleasant
symptom following its application. The patient, anesthetized, is
placed either in the semi-prone or the lithotomy posture and the
perineum retracted with a Sims speculum, through which the
vagina and cervix are thoroughly cleansed with a 1 : 3000 bichlo-
rid solution.* After fixing the cervix with a tenaculum or vol-
* When the Frisch specula are used, the patient is placed in the lithotomy posture.
MENSTRUATION AND ITS DISORDERS.
251
sella, the mucus is carefully wiped from the cervical canal with
antiseptic cotton held in dressing forceps. Impure or commer-
cial carbolic acid is next applied to the entire endometrium,
both cervical and corporeal, after which the curette, previously
dipped in carbolic acid, is passed into the uterine cavity. It is
then applied in such a way as to reach all parts of the uterine
cavity, thus removing fungoid masses, or the products of con-
ception, which can be saved for microscopic examination. An
especial effort should be made to reach the cornua uteri, for it is
in these localities that the products of inflammation are more
frequently found, and in two uteri removed per vaginam, I have
found small polypoidal masses imbedded deep into the tissues
of one horn. For a long time I used only Thomas's dull wire
FIG. 59.

GTIEMANN & CO
EMMET'S CURETTE FORCEPS.
curette (Fig. 46) looking upon the sharper instrument as both
dangerous and unnecessary. This prejudice was inherited from
Emmet, who has gone so far as to condemn in toto the use of
the curette, substituting for it his curette forceps (Fig. 59), whose
cutting edge enables the operator to remove the fungoid masses
by separating and approximating its blades. By observing the
counter-indications cited, together with the strictest antiseptic
precautions, I am convinced, both from personal experience and
the experience of men who have resorted to it many hundreds
of times, that the use of the sharp instrument, while it is
attended with no more danger than that of the dull, is infinitely
more effectual. I prefer Simon's sharp spoon curette to the
Sims (Fig. 45).
After the curetting the débris and blood should be removed
with absorbent cotton and the compound tincture of iodin
252
A TEXT-BOOK OF GYNECOLOGY.
(Churchill's), or carbolic acid, applied to the entire endome-
trium. The vagina is next packed with tampons saturated with
glycerin and liberally sprinkled with iodoform. This is done
for two reasons: first, a smart hemorrhage may follow the curet-
ting unless this precaution be taken; and second, any excess
of iodin or carbolic acid coming in contact with the vaginal
walls is at once neutralized by the glycerin. The patient is
placed in bed, where she should remain for four or five days;
if there is much pain the hot douche and the indicated remedy
are to be resorted to.
curette.
In the' foregoing description it is presupposed that the cervical
canal is sufficiently patulous to admit of the introduction of the
Indeed in most instances where curetting is indicated
the pathological conditions calling for it give rise to such patu-
lousness. Should, however, the canal be found too small to
admit the instrument it can be dilated by the introduction of
graduated sounds or by divulsion.
In general terms, then, the curette is indicated in uterine hem-
orrhage after less radical measures have been exhausted when
any of the primary pathological lesions enumerated have given
rise to secondary endometritis and uterine fungosities. Fibroid
tumors, polypi, subinvolution, uterine displacements, chronic
pelvic congestion,-any or all of these lesions frequently result
in changes in the endometrium necessitating its use. In malig-
nant lesions also it may be advantageously used as a prepara-
tory measure previously to total extirpation, or as a purely
palliative one in incurable carcinoma. When the hemorrhage
is due to subinvolution or hyperplasia the use of electricity may
accomplish much good.
Therapeutics.
China.-HEMORRHAGE FROM ATONY OF THE UTERUS; espe-
cially useful in those who have lost much blood, with ringing in
the ears, faintness, coldness, loss of sight, etc.; menses too early,
profuse and CONTAIN BLACK CLOTS; great distention of the abdo-
men. Cases of malarial origin, when the symptoms show a
marked periodicity, and also for women suffering from sexual
excesses."-Southwick.
((
MENSTRUATION AND ITS DISORDERS.
253
Ipecacuanha.-NAUSEA AND VOMITING; discharge of bright
red blood occurs with a gush at every effort to vomit; heat about
the head and debility; GASPING FOR BREATH; menses too early
and profuse. "If the hemorrhage is very severe and it seems
desirable to stop it at once, I give ipecacuanha, unless some
other remedy is characteristically indicated."-Winter burn.
Belladonna.-THE FLOW IS BRIGHT RED AND IMPARTS A
SENSE OF HEAT; bearing down, as if the organs would protrude
from the vulva; congestion of the head with throbbing of the
carotids.
Calcaria Carb.-Menses too frequent, too profuse and last
too long; profuse menstruation during lactation; LEUCOPHLEG-
MATIC CONSTITUTION.
*
Hamamelis.-PASSIVE HEMORRHAGE WITH ANEMIA; ABSENCE
OF UTERINE pains with a discharge of dark-colored blood; hem-
orrhagic diathesis with varicoses; ovarian irritation and inflam-
mation; leucorrhoea with great tenderness.
Sabina.-Menses too profuse, too early, partly fluid, partly
clotted and offensive; pains from sacrum to pubes; metrorrhagia
increased by least motion, but often worse from walking.
Platina. Metrorrhagia with dark, thick blood; pain in the
small of back, which extends into both groins; EXCESSIVE SENSI-
TIVENESS of the genital organs; great sexual excitement in preg-
nant females; sensitiveness of the ovaries with burning pain;
menses accompanied by spasm or by painful bearing down in
uterine region.
Crocus Sat.-Menorrhagia of dark, stringy blood; sensation
as if something alive were rolling or turning about in the abdomen;
metrorrhagia after abortion worse from the slightest motion ;
subinvolution.
Nitric Acid. Menses too early and too profuse, with urine
emitting an intolerably strong smell; the blood is very dark
colored and thick.-Guernsey.
Trillium.—Active uterine hemorrhage of dark, thick and
*"When the menses are too frequent and profuse, and especially if the patient is of
a strumous habit, with a tendency to pectoral disorder, calcaria carb. is, par excellence,
the appropriate remedy."-Ludlam.
254
A TEXT-BOOK OF GYNECOLOGY.
clotted blood, especially during climaxis; hemorrhagic diathesis,
pain in hips, short breath, palpitation, restlessness in legs.*
Secale Cornutum.-Passive hemorrhage with very fetid blood
in FEEBLE, CACHECTIC PERSONS, particularly when the weakness
was not caused by previous loss of blood (Jahr); frequent labor-
like pains with chronic metritis.
Erigeron. A profuse flow of bright red blood, aggravated
by the least motion; pallor and weakness in consequence of the
discharge.
Ferrum.—Menorrhagia in weakly persons with a fiery red
face; tenesmus of the bladder and diurnal enuresis ; sharp pains
in abdomen, bearing down in uterus, painfulness of the vagina.
Plumbum.—Menorrhagia with sensation of a string pulling
from abdomen to back; climacteric period; dark clots alternating
with fluid blood or bloody serum; Bright's disease, constipa-
tion with feces composed of hard balls.
Consult :-Agaricus, arnica, bovista, cactus grand, cantharis,
collinsonia, lachesis, phosphoric acid, pulsatilla, sepia, sulphur,
cannabis ind., hydrastis, lilium tig.
""
Illustrative Cases.
CASE XXIII.-Hydrastis Canadensis in Uterine Hemorrhage.-S. S., 51 years of
age, married, has four children, consulted me on April 15th, 1887, for "bleeding
from the womb, which has continued off and on since Christmas, 1886." Has always
been regular every month, the flow being profuse and lasting generally a week. Un-
til Christmas, 1886, had never suffered from metrorrhagia. On examination a hard,
irregular fibroid tumor was found occupying the anterior and left lateral wall of the
uterus. The sound passed for a distance of 3½ inches into the uterine cavity. The
new growth rose one inch above the fundus uteri on the left side. The patient was
ordered Pot. Brom. gr. x, and Ext. Ergot., Liq., mxxx, in a mixture three times a
day. On April 29th, a fortnight after her first visit, the "hemorrhage was still ex-
cessive." On May 20th, as the flooding still continued, a mixture of Pot. Brom. gr. x
and tinct. Hydrastis mxx was ordered, with the result that the hemorrhage ceased.—
Henry T. Rutherford, B. A., M. B. The British Gynecological Journal. Volume IV.
CASE XXIV. Cannabis Indica in Menorrhagia.—Mrs. B., æt. 34, mother of three
children, youngest five years old, has not been pregnant since this child was born.
*"One of the best remedies I know of in ordinary profuse menstrual flow, coming
frequently and yet without any decided constitutional character by which to judge the
case, is Trillium pendulum, especially if the flow exhausts the patient very much. I
have never given it in any potency except the sixth. That has been sufficient in all
my cases."-Farrington.
MENSTRUATION AND ITS DISORDERS.
255
Has for the last three or four years been troubled with profuse and frequently recurring
menstruation.
Present condition: Some eighteen days since her menses made their appearance,
since which time they have been very profuse and painful, the discharge being very
dark but without clots. Is very anemic, suffers great mental agitation, anxiety, irri-
tability, nervousness, loss of sleep (not having been able to sleep for two nights), pale
face, cold hands and feet, violent uterine colic, so severe as to induce cramps in the
extremities. For this condition she had had such remedies as arsenicum, china,
cyclamen, etc., and is apparently getting worse. As a dernier resort I prescribed
Cannabis Indica 1st. dec. dil. gtt. x in a tumbler half full of water, a teaspoonful
to be given every hour.
On my next visit I learned that after taking the third dose she became calmer, her
pains grew less and she fell into a gentle slumber. On waking the nervousness was
gone, the violent colic much better and all of her symptoms very greatly modified.
I continued the remedy at long intervals for three days, when she expressed herself as
being perfectly well. She has menstruated at regular periods three times since, and
each time with less difficulty until the last time, which she says lasted only four days
and was quite natural for the first time in three years. She has in the meantime taken
no other medicine except Cannabis Indica.-Richardson.
CASE XXV.-Mrs. H., æt. 30, has been confined to her bed for six days with a
violent menorrhagia, accompanied by a terrible uterine colic of a spasmodic nature,
the pains returning like labor pains; she has also great nervous agitation accom-
panied with sleeplessness. The can. ind. was given in three-drop doses of the Ist.
dec. dilution, every half hour; in a few hours she was very greatly relieved, and by
a continuance of the medicine she was in two days discharged cured.
I have given it in several other cases in which I neglected to note the details, but
the results being of such a nature as to prove it to be of great utility in those pros-
trating cases of menorrhagia in which the mental agitation and violent uterine colic
seem to be the predominating symptoms; in such cases I can at least advise the
profession to give it a trial.— Wm. C. Richardson, M. D., American Observer, 1871.
CASES ILLUSTRATING THE USE OF THE CURETTE IN UTERINE HEMORRHAGE.
CASE XXVI.—Mrs., æt. 38, married and the mother of three children. This patient
is exceedingly delicate and does not weigh more than ninety pounds. Has always
menstruated profusely, but since the birth of her last child, now eight years old, the
quantity of blood lost grew more and more excessive until she became almost ex-
sanguinated; the mucous membranes being blanched, the skin pale, and the anemic
murmur quite distinct. What little strength she could gain during the intermenstrual
period was entirely lost at the next appearance of the flow. Cannabis Indica,
together with the hot douche, controlled the hemorrhage in a measure, but the relief
was not lasting, the patient growing steadily worse.
On July 21st, 1891, ether was administered and the sharp curette applied. Large
quantities of fungoid débris were removed, which so much resembled that of diffuse
sarcoma as to make me exceedingly anxious until the microscope revealed its true
nature. The compound tincture of iodin was next applied to the entire endometrium,
and a supporting tampon placed against the cervix, which was removed as soon as the
vomiting ceased. The patient was kept in bed for two weeks and an antiseptic
256
A TEXT-BOOK OF GYNECOLOGY.
douche used twice daily. The first period was characterized by no perceptible
diminution of the discharge, nor was the improvement marked in the two following
periods. However, the loss of blood gradually diminished, so that in six months after
the curetting, instead of flowing excessively, the menses were scant. She rapidly
gained in strength and is now quite well.
CASE XXVII.-M., æt. 48, and unmarried. An interstitial fibroid large enough to
fill the lower pelvis was the cause of a uterine hemorrhage which at first was menor-
rhagic in character but soon became metrorrhagic; the flow, although worse at
certain times of the month, became almost continuous. I dilated the cervix under
ether and applied the sharp curette in the usual manner. The hemorrhage began to
diminish at once and did not become again excessive until one year from the time
of the first curetting. The operation was then repeated with equally good results.
The patient is still under observation.
These two cases show the usefulness of the curette when indicated, and it is unnec-
essary to multiply them. I have used the instrument many times and have rarely
been disappointed in the results obtained. Even where malignancy is suspected, and
the chief object of applying the curette is to obtain tissue for the microscope, it is my
practice to apply it most thoroughly, because the progress of a diffuse sarcoma or
carcinoma is often stayed by such a procedure. When the operation precedes
trachelorrhaphy it in most instances enhances the favorable results of the latter
operation, particularly if the lacerated cervix is associated with subinvolution and
menorrhagia.
CHAPTER XVIII.
MENSTRUATION AND ITS DISORDERS (Continued).
DYSMENORRHEA.

FORM.
ETIOLOGY.
SYMPTOMS.
DIAGNOSIS.
PROGNOSIS.
Neuralgic.
Gout and rheuma- Variable; pain sharp
tism; chlorosis;
malaria; anemia;
sexual irregulari-
ties.
and fixed or reflex;
time of pain vari-
able-before, dur-
ing or after thel
flow; aggravated
by cold drinks or
exposure.
Pains not expulsive; Depends upon
flow uninterrupted;
absence of clots and
physical causes.
cause and hab-
its of patient;
usually favor-
able.
Anything that will Pain for some days Pain precedes flow; Must be guard-
Ovarian,
the ovaries.
congest or inflame
Congestive and Congestion or inflam-
inflammatory.
Obstructive.
mation of any of
the pelvic viscera ;
undue exposure;
mental shock; dis-
placements; tum-
ors.
Cervical stenosis and
spasm; flexions;
polypi; tumors;
vaginal occlusions.
+
Membranous. Various theories;
usually associated
with endometritis.
before flow or dur-
ing intermenstrual
period. Charac-
ter.-Dull and ach-
ing, or sharp and
stinging, frequently
extending down
thigh; pain in the
breast.
enlargement, ten- ed.
derness, and fre-
quently displace-
ment of one or both
ovaries.
Sudden attack of Suddenness of onset; Depends upon
pain during men-
struation with sup-
pression; constitu-
tional disturb-
ances; vesical
and rectal tenes-
mus.
Menstrual symptoms
minus the flow; or
intermittent spas-
modic pain relieved
by a gush of blood.
Pain and flow simul-
taneous; labor-like
pains ceasing upon
the expulsion of
clots or mem-
branes: purulent
leucorrhea.
suppression
with cause; usually
favorable.
constitutional dis-
turbances; evi-
dences of local
disease.
Expulsive pains fol- Usually favor-
lowed by free dis- able.
charge of blood and
clots with relief;
flow intermittent;
presence of ob-
struction.
ed.
Periodical discharge Must be guard-
of membrane.
From abortion.—
History and repe-
tition. From blood
casts and casts
from the vagina.-
Microscopical ex-
amination.
General Considerations.-The term dysmenorrhea is purely
a relative one and is used to designate painful menstruation,
whether due to functional or to organic disease of the female
generative system. Like amenorrhea and menorrhagia it is a
17
257
258
A TEXT-BOOK OF GYNECOLOGY.
symptom of various disorders; and the division into forms only
serves to indicate, in a general way, some of the affections with
which painful menstruation is associated. The forms usually
given are: 1, Neuralgic; 2, ovarian; 3, congestive or inflamma-
tory; 4, obstructive; and 5, membranous.
This division also serves to explain the great difference of
opinion which exists among various authors regarding the cause
of the pain in dysmenorrhea. Thus some writers, notably Wylie
and Goodell, affirm that in all instances the pain is due to the
retention of the menstrual fluid, and the consequent distention
of the uterus. Emmet believes that anemia, inducing a tendency
to neuralgia, is the most prolific cause of dysmenorrhea; accord-
ing to this writer dysmenorrhea is oftener due to constitutional
than to local affections. Other writers attribute the pain in nearly
all instances to inflammation and disease of the uterine append-
ages. The probable truth is that no single explanation will apply
to any two cases of dysmenorrhea; and that the several causes
suggested by the older classification of Simpson and Thomas,
are more clearly in harmony with clinical facts than is a path-
ology based upon a single theory.
One or more of the causes enumerated might exist for an in-
definite length of time without giving rise to dysmenorrhea, were
it not that certain local changes induced by them render the nerves
supplying the uterus, the ovaries, or the surrounding structures,
morbidly sensitive. If the uterus or its annexa become hyper-
esthetic, a degree of distention which would give rise to no suf
fering in a perfectly normal organ may excite the most excru-
ciating pain in one thus affected; or the ordinary congestion of
menstruation may be sufficient to cause pain when local inflam-
mation has already induced this morbid state of the terminal
nerves; or anemia, chlorosis, rheumatism, malaria, etc., may
give rise to local distress, because the expression of pain inci-
dent to these various diathetic troubles oftener occurs in parts of
the body already weakened by local changes.
The clinician will rarely meet with any one form of dysmen-
orrhea uncomplicated, though the clinical manifestations of one
form frequently stands out with sufficient prominence to over-
shadow all others. Usually two or more varieties blend with
MENSTRUATION AND ITS DISORDERS.
259
one another so intimately as to make differentiation impossible.
Nevertheless, for the convenience of study, the classification is
useful.
Neuralgic Dysmenorrhea.-The etiology of this form of pain-
ful menstruation can be summed up in the term "neuralgic diathe-
sis;" a term which means so much and yet so little. Were a defini-
tion of it required, based upon accurate pathological deductions, it
would not be forthcoming. Nevertheless, there sometimes exists,
particularly in women, a peculiar state of the system which renders
the victim liable to sudden attacks of pain in various organs of the
body. Frequently there is a rheumatic or gouty basis to the diffi-
culty; or the general health may have become depreciated by
anemia, chlorosis or malaria. The victims of neuralgic dys-
menorrhea are oftener found among that class of women who
lead a sedentary and luxurious life, and, not infrequently, sexual
irregularities complicate matters. Painful menstruation is not
the only expression of the peculiar constitutional bias: gas-
tralgia, cardialgia, migraine, and other neuralgic manifestations,
are liable to occur from time to time, particularly if the patient
has been subjected to excesses or undue exposure of any kind.
The symptoms are as changeable as are the symptoms of
neuralgia generally. It is this peculiarity, however, which
enables the practitioner to detect the nature of the case in hand.
The pain may be sharp and fixed in some portion of the pelvis ;
or it may be shifting and reflected to any part of the body. Dr.
Thomas records two cases, in one of which, during each period,
the patient suffered intensely from pain limited to the outer side
of the little finger; the second experienced for several days before
the flow a violent pain at the root of the nose.
The occurrence of the pain relative to the flow is variable; it
may set in before, during or after the flow. It is often precipi-
tated by the slightest indiscretion, so that the patient cannot in-
dulge in a cold drink or an ice without suffering the penalty. It
will often vanish as suddenly as it appeared and the victim will
quickly pass from a state of acute suffering to one of compara-
tive comfort.
The diagnosis of this form of dysmenorrhea is to be made
by exclusion. The pains are non-expulsive, there is an absence
260
A TEXT-BOOK OF GYNECOLOGY.
of clots in the discharge, and a local examination will fail to
reveal the causes which give rise to the other forms about to be
considered. These facts, together with the diathetic history, will
afford sufficient data upon which to base a diagnosis.
The prognosis will depend upon the possibility of correcting
the constitutional trouble responsible for the mischief. With the
coöperation of the patient a cure can in most instances be accom-
plished.
Ovarian Dysmenorrhea.—Many authorities deny in toto
that ovarian lesions ever give rise to painful menstruation.
Indeed it is even contended by some that menstruation, instead
of aggravating existing ovarian lesions, relieves them by reliev-
ing pelvic congestion—a statement in proof of which there
exists certain clinical evidence. Nevertheless this does not
prove that ovarian irritation and inflammation may not play an
important part in the causation of dysmenorrhea; for, unless
we maintain that the ovaries play no part in menstruation (a
theory, as we have seen, which is hardly susceptible of proof),
it is but reasonable to presume that there may be transmitted to
the uterus a morbid as well as a normal ovarian stimulus. Ovarian
pain may be relieved by menstruation, because of the depleting
effect incident to the mere loss of blood; but before such relief
comes, an increase of suffering is caused by the dehiscence of a
Graafian follicle in an ovary the seat of pathological changes.
The etiology is that of ovarian irritation and inflammation.
Anything that will congest or inflame these organs may be the
indirect cause of ovarian dysmenorrhea. Cauterization of the
cervix, a practice which, fortunately, has justly fallen into disre-
pute, is especially emphasized by many writers as a causative
factor. Sexual excesses or irregularities are likewise prolific
causes. Frequently ovarian displacement, with or without
uterine, is associated with the dysmenorrheal trouble.
Symptoms. The pain of ovarian dysmenorrhea occurs and
persists for some days preceding the onset of the flow, and is
usually limited to one or both ovarian regions, oftener the left.
Not infrequently it extends down the corresponding thigh, and
reflex pain in the mammary region is often induced. In char-
acter the local pain is dull and aching, or stinging and burning.
MENSTRUATION AND ITS DISORDERS.
261
Dr. Priestly long ago called attention to what he termed an
"intermediate pain," occurring on a given day during each inter-
menstrual period. Whether or not this pain is due to intermen-
strual ovulation without menstruation cannot be determined.
The fact remains that in a certain number of cases of ovarian
dysmenorrhea this pain will recur almost to a certainty on a
given day. In one of my cases it occurred on the fourteenth
day after menstruation; in another on the twelfth-in each instance
persisting for several days.
Ovarian dysmenorrhea is to be differentiated from the other
forms: by the onset of the peculiar pain some days before the
appearance of the flow; by the tenderness and, frequently, dis-
placement of one or both ovaries; by the uninterrupted flow;
and by the absence of serious constitutional disturbance.
The prognosis must, under all circumstances, be guarded. So
long as menstruation continues the ovaries are subjected to a
periodical congestion which makes it exceedingly difficult to
cure an existing irritation or inflammation. The nearest approach
to "physiological rest" which can be given them is pregnancy
and lactation. Unfortunately ovarian dysmenorrhea occurs
quite as often in the unmarried as in the married; and when it
does present itself in the married the victims are frequently sterile.
Nevertheless the prognosis, under treatment which brings to the
patient a class of remedies not utilized by the older school, is
by no means as sinister as the writers of that school lead us to
believe. If irreparable damage has been done to the appendages
oöphorectomy remains as a last resource.
4
Congestive and Inflammatory Dysmenorrhea.—This form
of painful menstruation is accompanied with, and characterized by,
the symptoms of congestion and inflammation. It is indeed a
symptom of most of the inflammatory diseases of the pelvis, and
it is brought on by the same causes which give rise to congestion
or inflammation of any of the pelvic viscera. On the other hand
it may mark the beginning of inflammation. Undue exposure to
wet and cold during menstruation, is one of the most frequent
exciting causes.
The symptoms depend largely upon the degree of constitu-
tional disturbance excited by the local changes. When occur-
262
A TEXT-BOOK OF GYNECOLOGY.
ring as a primary condition there is usually a sudden attack of
pain during menstruation, with a partial or complete cessation of
the flow. If the congestion stops short of inflammation, the
constitutional disturbance will be limited to a slightly increased
intra-arterial pressure, with headache and nervous phenomena;
if, on the contrary, actual inflammation already exists, or if
the congestion incident to the menstrual suppression leads
to actual inflammation, the local suffering is that of pelvic peri-
tonitis. The pulse and temperature are increased, and there may
be marked delirium. Occasionally vesical and rectal tenesmus
become distressing.
The distinguishing features of this form of dysmenorrhea
are: I, the sudden onset of pain with the more or less complete
suppression of the flow; 2, the constitutional impression, which
is sometimes profound; and 3, the evidences of local tenderness
or lesions obtained by physical exploration.
Prognosis.-The prognosis will necessarily depend upon the
cause or causes giving rise to the dysmenorrhea. If the local
changes are limited to simple hyperemia, the equilibrium is easily
restored by proper treatment and the succeeding menstrual
period is not characterized by marked suffering. However, if
the products of inflammation are left behind, or if the dysmen-
orrhea is due to preëxisting cellulitis or peritonitis, the pros-
pects of relief will depend upon the curability of the pelvic
lesion.
Obstructive Dysmenorrhea.—The causes giving rise to ob-
structive dysmenorrhea are stenosis of the cervical canal and
spasm of the circular muscular fibers in the region of the in-
ternal os, flexions, polypi and tumors, and vaginal occlusions.
Cervical stenosis may be congenital or acquired. If congenital
the condition is usually associated with an undersized uterus and
the menses are scant; if acquired it is often the result of power-
ful applications to the cervix, or it may follow in the train of
amputations and trachelorrhaphies. There can be no doubt that
spasm of the circular fibers of the cervix is sometimes sufficiently
great to cause partial or complete occlusions, giving rise to what
has been defined by some writers as "spasmodic dysmenorrhea.”
At any rate a certain number of dysmenorrheal cases are met
MENSTRUATION AND ITS DISORDERS.
263
with presenting all of the phenomena of obstruction, so far as
subjective symptoms are concerned, in which the cervical canal
upon physical exploration seems perfectly patulous. Patients
thus affected are usually of the neurotic type, and their suffering
is best relieved by remedies having a special affinity for the
nervous system.
Flexions are probably more often the cause of obstruction
that anything else. For obvious reasons simple version is not
so liable to impinge upon the canal, yet it is entirely possible for
a retroversion to so crowd the external os against the anterior
vaginal wall as to interfere with the exit of the menstrual dis-
charge. Polypi and tumors produce obstruction in a purely
mechanical way. Dr. Thomas especially emphasizes the fact
that a small polypus, by dropping against the internal os, thus
acting as a ball-valve, may cause marked obstruction which is
difficult to detect because a probe readily pushes it aside in
penetrating the uterine cavity. The most frequent cause of
vaginal occlusion is an imperforate hymen. However, slough-
ing of the vagina as a sequel of childbirth may result either in
complete or partial obliteration of the canal; in complete oblit-
eration the menses are, of course, retained.
It is worthy of note that certain eminent specialists deny the
existence of this form of dysmenorrhea. I heard the late
Mathews Duncan, in a lecture delivered at St. Bartholomew's
Hospital, London, affirm that so long as the menstrual blood
can escape from the uterine canal, no matter how small the
opening may be through which it makes its egress, no pain will
be caused by the obstruction. In proof of this affirmation he
cited the fact that many women possessing a cervical canal not
large enough to admit the finest probe, menstruate without the
least pain; that women with a "pin-hole os" will sometimes
bleed to death; and, finally, that in many of the cases of so-
called obstructive dysmenorrhea it is perfectly possible to pene-
trate the uterus with a large-sized probe during the intermen-
strual period. In our own country Dr. Emmet and others hold
nearly, if not identically, the same views.
*
* For an extended dissertation on this subject see " Transactions of the American
Gynecological Society," Vol. VIII, p. 101.
264
A TEXT-BOOK OF GYNECOLOGY.
Undoubtedly, in a certain number of cases, the foregoing
statements are in harmony with clinical facts; nevertheless, in the
vast majority of dysmenorrheas presenting the symptoms of
obstruction, the evidences of such obstruction are to be obtained
upon physical exploration; besides the symptoms entirely vanish
after thorough dilatation. Moreover, an obstruction may exist
during menstruation and entirely disappear after the flow ceases;
or the obstruction may be of the nature of a polypus which
would admit of the ready passage of a sound and which could
be detected only by exploring the uterine cavity with the finger.
The fact that the spasmodic pains which characterize obstruc-
tive dysmenorrhea are followed by a discharge of clots from the
uterine cavity, proves conclusively that the blood has been
retained long enough for coagula to form, which would be
impossible did not some obstruction exist.
Symptoms.-The symptoms are those following upon disten-
tion of any of the hollow viscera. The uterine cavity, after
reaching a certain degree of distention is excited to contraction,
and the efforts made to expel its contents result in pain. A gush
of clotted blood terminates the suffering, which does not recur
until the organ is again distended. The degree of suffering will
depend largely upon the persistence of the obstruction, and when
it is exceedingly difficult to overcome, the spasmodic pains may
continue for some hours before the flow makes its appearance.
Diagnosis.-The intermittent character of the pains, coming
and going at regular intervals, temporarily relieved by a free
discharge of blood which often contains clots, is pathognomonic
of obstructive dysmenorrhea. Exploration per vaginam and
with the sound will usually locate the seat of the obstruction.
The exceptions to this rule already noted should, however, be
borne in mind. The spasmodic constriction of the circular
muscular fibers may have entirely disappeared before an exam-
ination is made, and, indeed, the spasm may not recur at each
succeeding menstrual period. A test, to my mind far more con-
clusive in determining the part played by the spasm, is the effect
of gradual dilatation, which is discussed under the head of
treatment.
The prognosis is usually favorable, perhaps the most so of
any
MENSTRUATION AND ITS DISORDERS.
265
of the forms of dysmenorrhea. It is, of course, modified by the
existing complications, the most serious of which are inflam-
mation of the uterus and its surrounding structures. As long as
the ovaries are uninvolved, however, and as long as the condi-
tion of the patient does not forbid surgical interference, obstruc-
tive dysmenorrhea is probably the most amenable to treatment
of all forms.
Membranous Dysmenorrhea.-Pathology.-This form of
dysmenorrhea is unlike any of the foregoing in that organized
material is expelled from the uterus at each menstrual period.
This material consists of the menstrual decidua, which is thrown
off in sections or occasionally en masse, when the triangular sac
represents a cast of the uterine body. There is such a conflict of
opinion regarding the nature and cause of this peculiar process as
to make it unprofitable at this time to discuss the various theories
at length. Instead I shall quote the conclusions of Dr. John
Williams, contained in a paper presented to the " London Obstet-
rical Society" at a recent meeting. These conclusions are valu-
able, both for the reason that Dr. Williams has drawn his deduc-
tions from a series of cases which were for many years under his
observation, and because he has made a study of the changes in
the endometrium during menstruation. They are as follows *:
1. The dysmenorrheal membrane is not the product of conception, but the decidua
ordinarily shed as débris with every menstrual epoch.
2. It is expelled as a whole or in masses, in consequence of the presence of an
excess of fibrous tissue in the wall of the uterus; this excess is due to imperfect evo-
lution at puberty, imperfect involution after parturition or abortion, or is the product of
acute inflammation.
3. The membrane is neither the result of an ovarian congestion, nor of an hyper-
trophy of the ordinary decidua.
4. The chronic inflammation present is usually the result of the monthly expulsion
of the decidua from the uterus, and plays an accidental part only in its production;
the inflammation may, however, be independent of the expulsion of the membrane,
but it has no causal relation to the formation of the latter.
5. Sterility is not necessarily associated with the affection, but is the result of the
condition induced by the expulsion of the membrane from the uterus-inflammation
of the uterus and ovaries.
6. The membrane may be expelled without pain.
* Edis, "The Diseases of Women," p. 483.
266
A TEXT-BOOK OF GYNECOLOGY.
7. Inflammation of the uterus greatly aggravates the suffering caused by the pas-
sage of the membrane along the cervical canal.
8. Great relief may be obtained by curing the inflammation of the cervix, though
the membrane continues to be expelled every month.
9. In order to effect a cure, the structure of the body of the uterus must be changed.
Symptoms.—These resemble the symptoms of early abortion.
The pains are labor-like, bearing down, coming and going with
more or less regularity, increasing in intensity until, finally, the
expulsion of a large clot, whose nucleus is a piece of membrane,
or the expulsion of the whole lining of the uterine body, affords
relief. The pain and flow occur simultaneously, and the flow is
usually excessive. The expulsive efforts are sometimes so vio-
lent as to cause the most intense suffering, and even delirium and
convulsions.
Patients who have long suffered from this form of dysmen-
orrhea are not entirely free from distress during the intermenstrual
period. Purulent leucorrhea, because of the existing endo-
metritis, is often a persistent symptom. Frequently, too, the
victims complain of a general weariness, with more or less
constant pain in the abdomen and back, which often extends to
the iliac fossæ and down the inner side of the thighs. They
look forward to the approaching period with much dread, and
the periodical recurrence of menstruation, together with exces-
sive drain resulting from the menorrhagia and leucorrhea, sooner
or later induce a state of chronic invalidism.
It is necessary to differentiate membranous dysmenorrhea from:
I, early abortions; 2, casts from the vagina; 3, casts from the
bladder and pelvis of the kidney; and, 4, blood polypi.*
The prognosis, as to cure, is decidedly unfavorable and must
always be cautiously given. Many remedies and expedients of
reputed merit have been brought forward, but in due time have
fallen into disrepute. A very large per cent. of those suffering
from the complaint are, unfortunately, sterile, and even if con-
ception occurs abortion is liable to follow. If the views of Dr.
Williams are correct, the changes resulting from utero-gestation
would undoubtedly be beneficial. Much relief can, however, be
*
v. page 73.
MENSTRUATION AND ITS DISORDERS.
267
afforded by treatment directed toward the existing inflammatory
complications, and, indeed, many absolute cures have been re-
ported. These have been accomplished, not by any one routine
method of treatment, but by almost as many methods as there
are cases recorded. A survey of the literature of the subject
forces upon one the conclusion that membranous dysmenorrhea,
like most other symptoms, requires a careful study of each indi-
vidual case. At least a larger ratio of cures are to be found in
the literature of the homeopathic than in that of the older school
of medicine, and these have been obtained by combining with
the local treatment the administration of the indicated remedy.
Nevertheless, the number of absolute cures is discouragingly
small and shows the necessity of guarding the prognosis even
under the most favorable circumstances.
THE TREATMENT OF DYSMENORRHEA.
General. This will depend, to a certain extent, upon the
form of dysmenorrhea which obtains. In the neuralgic, for
instance, constitutional measures must be adopted tending to
overcome the causes which have induced the neuralgic habit.
Thus anemia, chlorosis, rheumatism, malaria, etc., when present,
should receive attention. Out-door exercise, a liberal diet, sea
bathing, or, if this cannot be practised, a daily sponge bath, are
adjuvants of the greatest value in the treatment of the neuralgic
diathesis. Flannel should always be worn next to the body, for
most neuralgic subjects are exceedingly sensitive to cold.
Electricity is of the greatest value in the treatment of this and
of nearly all forms of dysmenorrhea.* It must, however, be in-
telligently applied and the cases selected with the same discrimi-
nating care observed in the selection of the homeopathic remedy.
It is not a cure-all," nor should it be so considered.
Since using electricity I have discarded entirely the galvanic
stem pessary. The remedies more often useful when the neu-
ralgic symptoms predominate are: Gelsemium, ignatia, cham-
omilla, magnesia phos., coffea, and cimicifuga.
The suggestion made by Dr. R. Ludlam, that the remedies be
*v. Chapter XI for the technique of application.
268
A TEXT-BOOK OF GYNECOLOGY.
administered in warm water, is a wise one, for it is surprising
how susceptible these patients are to cold or cold drinks. Heat,
in the form of hot applications, hot sitz bath, or the hot
douche, is, in any variety of dysmenorrhea, most useful during
the paroxysm of pain, especially if the flow is suppressed
or scant.
In ovarian dysmenorrhea the causes tending to keep up the
ovarian irritation should, if possible, be removed. A careful in-
quiry into the sexual habits of the patient will often reveal most
pernicious practices which, so long as persisted in, make it im-
possible to accomplish a cure. Oftentimes a temporary marital
separation is necessary. Galvanism, with the positive pole direct,
will, I believe, do more for simple ovarian irritation than any
other agent. The more prominent remedies possessing a special
affinity for the ovaries are: Belladonna, apis, lilium tigrinum,
cocculus, and pulsatilla.
The congestive and inflammatory forms of dysmenorrhea re-
quire measures similar to those useful in pelvic cellulitis and
peritonitis. An effort should be made to restore the discharge
when it has been suppressed, and actual inflammation should be
aborted if possible. The hot douche is probably the most useful
agent to accomplish this end, supplemented by such remedies
as aconite, belladonna, veratrum viride, pulsatilla, gelsemium,
and ferrum phos.
While the general measures which have been suggested for
the relief of pain will be found useful during a paroxysm of
obstructive dysmenorrhea, the radical treatment is very different.
The obstruction requires for its removal mechanical and surgical
interference. Those of the vagina are to be dealt with according
to the principles laid down in the chapter devoted to vaginal oc-
clusions. Cervical obstructions due to flexions and other forms
of uterine displacement require measures for the correction of
the displacement, and much relief may be obtained by a properly
adjusted pessary. If the flexion is marked, however, and espe-
cially if it is congenital, divulsion is usually necessary before a
cure is effected. I have now resorted to the operation so often
and am so well satisfied with the results obtained that I deem it
best to give at some length my method of procedure. In a given
MENSTRUATION AND ITS DISORDERS.
269
case of dysmenorrhea presenting the symptoms of obstruction
it is as follows:-
If the patient comes to me soon after a menstrual period I
make an examination and determine, if possible, the seat of the
obstruction. In the great majority of cases it will be found at
or near the internal os, at which point the mucous membrane is
often exceedingly sensitive. If there is congestion or inflamma-
tion of the cervix and uterus, and there usually is, the hot douche
once or twice a day is advised, and at least twice a week I place
against the cervix and into the fornices of the vagina tampons of
boro-glycerid or pure glycerin, medicated as may seem best.
These are removed at the end of twenty-four hours and are fol-
lowed by the douche. Some three or four days preceding the
approaching period, having reduced the congestion by the pre-
paratory treatment, I cautiously introduce several sizes of the
hard rubber dilators (Fig. 43). This is repeated at least twice before
the onset of the period in order to ascertain the effect of dilata-
tion. If the effect is good, menstruation will be less painful and,
if the obstruction is the result of spasm, permanent relief may
be obtained by repeated introductions of the graduated sounds
during the succeeding intermenstrual period. Permanent results
are, however, the exception to the rule, and the utility of gradual
dilatation is restricted largely to determining the probable effect
of the more radical operation. It can be done in the office and
should not cause anything more than passing pain.
If the patient reports her dysmenorrhea for one or more
periods relieved by this procedure, and if in due time there is a
return of the old suffering, divulsion is indicated. This must
be done at her home and every precaution taken to guard
against sepsis and inflammation. The bowels should be previ-
ously emptied by an enema, and an antiseptic douche adminis-
tered shortly before getting on the table. An anesthetic is
always necessary. The patient is placed in Sims' posture, a
Sims speculum introduced, and the vagina again washed with
a I: 3000 bichlorid solution. The cervix is then fixed with a
volsella, a sound introduced to ascertain the direction of the
canal, upon the withdrawal of which an application of carbolic
acid is made as directed for the operation of curetting. The
270
A TEXT-BOOK OF GYNECOLOGY.
steel dilator represented in Fig. 44 is next passed into the uterine
cavity and the blades gradually expanded. I emphasize the
word "gradually" because, if an effort be made to divulse with
• too great haste, there is danger of unduly lacerating the tissues.
At least ten minutes should be devoted to the operation and the
canal dilated to the extent of half, three-fourths, or an inch,
depending upon the size of the uterus and the resistance of the
tissues. Undersized uteri, with congenital anteflexion, will not
bear the same amount of dilatation without injury as will fully
developed organs. The amount of force required in different
cases will likewise vary greatly, and judgment must be used in
applying it. Usually, however, it is considerable—all that can
be exerted by one hand. If the tissues are felt to tear it should
be lessened. The object is to stretch the tissues to the extent
indicated without serious laceration.
After the dilatation is completed the uterine cavity is washed
FIG. 60.

G.TIEMANN &Co.
CLEVELAND'S GLASS CERVICAL PLUG.
with a 1 : 3000 bichlorid solution and impure carbolic acid again
applied to the entire surface. If menorrhagia complicates the
dysmenorrhea, I apply the sharp curette to the entire endome-
trium. A glass plug (Fig. 60) is then introduced into the
uterine cavity, and secured with a silver wire suture. A tampon
sprinkled with iodoform is placed against the cervix for the
purpose of supporting the parts if vomiting occurs, and the
patient is placed in bed.
The after-treatment is very simple and consists of a small an-
tiseptic douche after each urination, rest in bed for ten days, at
which time the plug is removed and the patient is permitted to
get up. The tampon is removed at the end of ten hours.
This is the ordinary technique followed by me, and it will be
seen that it differs somewhat from that of either Goodell or
Wylie-the two chief apostles of rapid dilatation in America.
First of all, I restrict myself to the graduated dilators for office
MENSTRUATION AND ITS DISORDERS.
271.
work. I have abandoned entirely the cutting operation as being
not only unnecessary, but much less effectual than is divulsion
without it. And last, but not least, I have adopted the practice
of retaining the plug with a suture instead of endeavoring to
keep it in place with tampons. The tampons do not always suc-
ceed in maintaining the plug in its proper position; it is necessary
to change them often, and they interfere with uterine drainage.
If the wire is used nothing further is necessary until the plug is
removed, which is easily done.
In those cases complicated with rectal trouble,—constipation,
hemorrhoids, etc., it is my invariable practice to stretch the
rectal sphincter and to remove any morbid condition that may
exist in the rectum.
Indeed, if the patient complains of vaso-motor disturbances as
indicated by cold hands and cold feet, or if she has been unusu-
ally nervous, I thoroughly divulse the sphincter ani, even
though she has suffered no local distress in the rectum. I
cheerfully acknowledge my indebtedness to the teachings of Dr.
E. H. Pratt for this practice, and I am thoroughly convinced
that the good to be derived from divulsion of the cervix is
greatly enhanced by directing attention to the rectal sphincter
as well.
This treatment is advised with the full consciousness that it is
not in accord with the teachings of many specialists, especially
of the homeopathic school. Four years ago I was likewise very
much prejudiced against divulsion, and advised against it in my
classes. It seemed to me then, as it does to many now, a most
dangerous and unnecessary procedure-a conviction which was
intensified by two cases of cellulitis occurring in my practice,
the result of the operation. I found, however, that the average
patient suffering from obstructive dysmenorrhea, particularly if
the dysmenorrhea were associated with the nervous phenomena
already described, remained permanently on my hands, the most
that I could accomplish with the ordinary methods being tempo-
relief. I then selected my cases with greater care, resorted to
proper preparatory treatment, and observed the strictest antiseptic
precautions, since which time I have not had one unfortunate re-
sult and have hardly failed to relieve permanently a single case
rary
272
A TEXT-BOOK OF GYNECOLOGY.
operated upon. As regards sterility I have not cured as large
a per cent. of my cases as is reported by Goodell, yet the results
have been encouraging. In properly selected cases the transfor-
mation brought about is simply marvelous, especially if the rec-
tal sphincter is treated as well. The menstrual function becomes
painless, and the patient is raised from a state of chronic invalid-
ism to one of comparative robustness.
For the pain incident to membranous dysmenorrhea the same
general measures adopted for the several other forms are useful.
Dilatation is often exceedingly beneficial, and while it does not
put a stop to the membranous formation, it will make its expul-
sion much less painful. Dilatation also promotes uterine drain-
age and facilitates intra-uterine medication. Whether or not it
exerts an influence upon the nutrition of the uterus through its
action upon the sympathetic system, is a point worthy of consid-
eration. It is not unreasonable to presume that it does.
The local applications under which cures have been affected are
those of an alterative character. Carbolic acid, iodin, chromic
acid, iodoform, persulphate of iron, etc., are the ones which have
been most frequently used. The remedies administered in the
successful cases recorded in homeopathic literature are: Borax,
rhus tox., calcaria, mercurius, bromine, millefolium and guia-
cum.
Therapeutics.
Gelsemium.-Difficult menstruation; the periods are pre-
ceded by sick headache and vomiting; congestion of the head,
with a dark suffused appearance of the face; large quantities of
limpid, clear urine, which relieves the headache; uterus is mark-
edly congested and feels as if squeezed by a hand; sharp labor-
like pains in the uterus, extending to the hips and back and even
down the thighs.
Cimicifuga.-SEVERE PAIN IN THE BACK, DOWN THE THIGHS
and through the hips, with heavy pressing down; rheumatic
diathesis; tenderness of the uterus; great despondency; occipi-
tal headache; between the menses debility, nervous erethism
and neuralgic pains; insomnia; INFRA-MAMMARY PAINS.
Pulsatilla. Neuralgic dysmenorrhea; the menses are delayed,
difficult and scanty; menses suppressed or flow intermittent,
MENSTRUATION AND ITS DISORDERS.
273
with throbbing headache; pain in the uterus; dysuria; ophthalmia;
gastric disturbance with vomiting; morning nausea with bad taste
in mouth; worse in warm room; mild, yielding, tearful disposition.*
Belladonna.-Congestive and neuralgic type; PAINS COME
AND GO IN QUICK SUCCESSION; violent bearing down, as if every-
thing would issue from the vulva; violent throbbing headache,
better from external pressure.
Caulophyllum.-Painful contractions, congestion and irritabil-
ity of the uterus; sympathetic cramps in the bladder and rec-
tum; spasmodic intermittent pains in the stomach, groins, and
even in the chest; rheumatism of the small joints.
Magnesium phos.-Menstrual colic; spasmodic pain in the
uterus; inability to pass water, from spasmodic contraction;
crampy pain in stomach or bowels, with a feeling as if tightly
grasped by a band.
Calcaria Carb.-Suppressed menses after working in water,
with a tendency to cerebral congestion; SCROFULOUS DIATHESIS;
coldness of the feet, and very easily affected by the cold air.
Apis mellifica.-Ovarian dysmenorrhea; STINGING PAIN IN
THE OVARIES; urine is scant and high colored; violent, labor-
like, bearing down pains, followed by a discharge of scanty, dark,
bloody mucus.
Borax.-Menses too early, too profuse and attended with colic
and nausea; leucorrhea like the white of eggs; sensation as if
warm water were flowing over the parts; membranous dysmen-
orrhea.
Platina.-PAINFUL SENSITIVENESS AND CONTINUAL PRESSURE
IN THE REGION OF THE MONS VENERIS AND GENITAL ORGANS;
menses too early, too profuse but of short duration, preceded by
spasm with bearing down, and during the flow pinching in abdo-
men, with excruciating pains in uterus; melancholia.
Secale corn. Menstrual discharge of thin and black or brown
fluid, which is exceedingly offensive; tearing and cutting uterine
colic, with violent uterine spasms.
*"Pulsatilla is at times to be used for menstrual colic, particularly when the
menses are dark in color and are delayed. The flow is usually fitful. The
patient is apt to be chilly; and the more severe are the pains the more chilly does she
become."— Farrington.
18
274
A TEXT-BOOK OF GYNECOLOGY.
Cocculus.-Cramp-like pains deep in the bowels, instead of
menses, with pressure in chest; vicarious leucorrhea; scanty
discharge of black blood.
Coffea. Continuous pinching pain in the iliac region; cold-
ness and stiffness of the body; neuralgic dysmenorrhea.
Colocynth.-Dysmenorrhea relieved by drawing the lower
limbs up to the abdomen.
Cantharis.-Violent pinching pains in the ovarian region;
menses too early, too profuse; blood black and scanty; violent
itching in the vagina with dysuria; dryness and feeling of con-
striction in throat.
Ignatia.-Cramp-like pains in the uterus with lancinations
worse from touching the parts; a feeling of confusion in the
head, with inability to closely apply the mind; despondency,
depression, sadness; CONVULSIONS, FREQUENTLY TETANIC; feel-
ing of constriction in the throat, like globus hystericus.
Helonias.-Loss of sexual desire and power, with or without
sterility; profound melancholia, with marked debility; pain in
the back, through to the uterus; menorrhagia.
Lilium tig.-Burning, sticking, grasping pain in the ovaries,
especially the left; pains extending across hypogastrium, to
groin, down the leg; bearing down in uterine region; neuralgia
of the ovaries, attended by cutting pains in mammæ.
Sepia.-Most useful as an intercurrent remedy; BEARING
DOWN SENSATION, WITH A FEELING THAT THE LIMBS MUST BE
CROSSED SO AS TO PREVENT PROTRUSION OF THE PARTS; excoriat-
ing leucorrhea; "moth spots" on various parts of the body; pain-
ful sensation of emptiness in stomach and abdomen.
Bryonia. Stitching pain in the ovaries on deep inspiration;
menses too early, too profuse, or suppressed, with vicarious
bleeding from the nose.
Bromine.-Violent contractive spasms before or during men-
ses, leaving the abdomen sore; menses too early, too profuse;
bright red blood with the expulsion of membranous shreds.
Mercurius.-Deep sore pain in the pelvis with dragging in
the loins; smarting, corroding, purulent leucorrhea, always
worse at night.
Nux Vomica.-Contractive uterine spasms; colic with dis-
MENSTRUATION AND ITS DISORDERS.
275
charge of coagula; bearing down toward the sacrum; ineffectual
urging to stool; DYSMENORRHEA COMPLICATED WITH FLATULENT
COLIC AND GASTRIC DISTURBANCE.
Viburnum opulus.-Spasmodic and membranous dysmen-
orrhea; excruciating colicky pains through uterus and lower part
of abdomen, coming on suddenly just before the menstrual flow,
lasting sometimes ten or twelve hours.
Consult:- Ustilago maydis (membranous dysmenorrhea),
sanguinaria, ferrum phos., hyoscyamus, lachesis, rhus tox, zin-
cum, cuprum met., aconite, collinsonia, glonoin, graphites,
xanthoxylum, and millefolium.
Illustrative Cases.
CASE XXVIII.-Borax in Membranous Dysmenorrhea.—In a case of membranous
dysmenorrhea of some months' duration Dr. A. P. Throop relates the following: As
suggested by Prof. Ludlam of Chicago, I prescribed borax I x three times a day, till
the next period.
The next period occurred the 25th of October.
Dysmenorrhea much less, no cast;
only shreds, less in size than for months, and the general condition better.
The last prescription of borax was given Nov. 21st. In January, 1872, I called at
the patient's home, being desirous of knowing the sequel of the case, and ascertained
that there had been no more dysmenorrhea, as the period had not again appeared, and
the patient was pregnant. As pregnancy and membranous desquamation from the
inner wall of the uterus are not compatible, the membranous dysmenorrhea is sup-
posed to be cured.
On the seventh of August, 1875, she gave birth to a fine, healthy female child, and
there have been no symptoms since of any uterine trouble.-N. Y. Homeo. Med. So-
ciety Transactions.
Case XXIX.—Platina in Dysmenorrhea.—Oct. 23, 1888, I was called to see Mrs.
A., æt. 35, nervo-sanguine temperament, and the mother of two children. I found her
suffering from dysmenorrhea. She informed me that she had been subject to this
trouble ever since puberty; had been under the treatment of four different physicians
without benefit, and had grown steadily worse since the birth of her children.
Menstruation was regular and normal in quantity and quality, but accompanied by
severe spasmodic pains extending from the uterus to the groins and upper part of the
thighs. She was extremely nervous, and one foot was in constant motion, beating
the bed-clothes with the rhythmical regularity of machinery. While telling her
symptoms, she suddenly became rigid and unconscious; the jaws were firmly locked,
the forearms flexed upon the arms, the legs extended, and the whole body bent
slightly backward. After a few moments she regained consciousness and the regular
motion of the foot again commenced and continued until interrupted by another tonic
spasm.
Her husband stated that during every menstrual period she had from four to ten of
276
A TEXT-BOOK OF GYNECOLOGY.
these attacks, varying in duration from five minutes to half an hour. Cimicifuga 3 ×
was given, but failed to relieve.
One week later, a thorough examination was made, but nothing abnormal could
be detected except an undue sensitiveness of the internal os during the passing of the
sound.
Failing to find any mechanical cause, and being firmly convinced that the trouble
was mainly hysterical, I now gave Ignatia 30 x. The result was another failure, a
discouraged patient, and a determination to stop prescribing on pathological theories
and to treat the case according to symptomatic indications.
""
After a long search, "tetanic spasms with trismus during the menses
was found
under platina. Was called again at the termination of the first day of the next men-
strual period, and gave platina 30 x in water, every two hours. The spasms ceased at
once and have never since recurred. In other respects, the improvement was more
gradual; but after taking the remedy during the menses for the next four months, the
flow became comparatively painless and the patient was discharged. As nearly two
years have now elapsed without a return of the old symptoms, the cure may be con-
sidered permanent.—Dr. W. T. Laird, N. A. Journ. of Homeopathy, May, 1891.
•
CASE XXX.-Viburnum Opulus in Dysmenorrhea.-In my treatment of spasmodic
dysmenorrhea, for which variety this remedy is specifically indicated, when the pain sets
in, I give Viburnum op. every hour, or every fifteen minutes if the pains are severe.
So confident have I been in its almost marvelous powers that I have taken the pains to
look up some old cases that I had dismissed years ago as incurable, in order to test
this new remedy on them.
In every instance so far it has cured these old obstinate cases. Its sphere of action
seems to cover nearly the same ground as galvanism. In the last number of the
N. A. Journ. of Homeo., Dr. Neftel has a valuable paper illustrating the curative
power of galvanism. He gives many illustrative cases, and singularly enough, they
all resemble the cases I have cured with Viburnum. I use the Ist.dec. dil.—E. M.
Hale, M. D., American Observer, 1874.
CASE XXXI.-Viburnum Opulus in Dysmenorrhea.-Two years ago my attention
was called to the use of Viburnum Opulus, as a remedy for dysmenorrhea, or menstrual
colic. Having a patient who was suffering from this difficulty, I procured the rem-
edy for the purpose of a trial. Her symptoms were: an excruciating colicky pain
through the womb and lower part of the abdomen, coming on quite suddenly just
preceding the menstrual flow.
I had failed to do her much good, though
caulophyllum had relieved her sometimes. I gave her Viburnum 1st decimal dilu-
tion, three-drop doses, to be repeated in half an hour, if not relieved. The first dose
relieved her, and she took but two. During the interval of the next period I directed
her to take one drop, once a day, and if the pain returned at the next time, to take
three drops and repeat as before. Suffice it to say, she had but a slight return of
the colic, and now reports herself as cured.-Geo. B. Palmer, M.D., American
Observer, 1877.
CASE XXXII.-Cocculus in Dysmenorrhea.—I have found this drug useful in cases
of regular, irregular, and suppressed menstruation, the flow in most cases having been
very profuse, accompanied by severe uterine colic, with bearing down in pelvic region
and intense lumbo-sacral pains.
In every case where I have found it useful
MENSTRUATION AND ITS DISORDERS.
277
in dysmenorrhea, the patient has had a thick, yellow leucorrhea, and in most cases
granular degeneration of the cervix.
Where uterine disease existed, dys-
pepsia, characterized by nausea and flatulence was, with few exceptions, more or less
pronounced during the intermenstrual period.-Emma Scott Wright, M. D.,
Transactions of the Homeo. Med. Society of the State of New York, 1878.
CASE XXXIII.—Xanthoxylum in Membranous Dysmenorrhea.-Mrs.—, aged
twenty-five years, tall, slender, of light complexion, somewhat stooping, emaciated,
anemic; has the appearance of a consumptive. Used to be a rugged, hearty girl; has
been married three years; has suffered intensely with dysmenorrhea and has never
been pregnant. Menstruation was so painful that she was obliged to remain in bed
for several days, from which she would get up so utterly prostrated that she could not
rally before her next period came on. Menstruation was normal as to time; the pains
were contractive, with great bearing down; the flow was slight; the intensity of her
suffering caused her to keep her limbs in constant motion, drawing them up and down
in bed, in spite of urgent advice to the contrary. Cocculus and, later, belladonna gave
considerable relief. Examination of the napkins used confirmed my diagnosis, viz:
membranous dysmenorrhea. Xanthoxylum 2d dec. trituration, three doses each day,
acted so favorably that her next period was remarkably free from pain; she was dis-
charged in about three months, looking hearty and well. In the course of a year she
gave birth to a healthy child, and has been quite free from disease during a period of,
now, five years.—Dr. I. N. Eldridge, Medical Counselor, Vol. x.
CASE XXXIV.-Membranous Dysmenorrhea. Milfoil Internally and Iodized
Phenol Topically.—Mrs. H., the mother of two children; six years after the last con-
finement she came to me to be treated for sterility. I learned that about a year ago
she observed that the pain during menstruation became very severe; each period more
severe than the former. The pains were forcing labor-like, in the back and down the
thighs; the blood was dark and clotted, and on the last day (usually the sixth) a mem-
branous mass would be expelled, when the pain would cease. An examination of
these membranes showed them to be such as are described as pseudo-membranous.
The treatment was commenced one week before the menstrual period. It consisted
in applying to the endometrium, by means of a probe wrapped with absorbent cotton,
a mixture of tinct. iodin, I part; 50 per cent. carbolic acid I part. Internally I
ordered Inf. Milfoil, prepared by infusing zij of the dried herb in one pint of
hot water, 3j to be taken three times a day. I only made one application topically.
She returned to her home in Iowa.
One week after her menses ceased she wrote to me that she had no pain during
the menses, the blood was normal in appearance and no membrane was expelled. I
requested her to report after the next period, if it were not normal. Two months
have now elapsed (two menstrual periods) and I have not heard from her. She is
probably cured.-E. M. Hale, M. D., Homeo. Journ. of Obstetrics, 1886.
Case XXXV.—Guiacum in Chronic Ovaritis with Dysmenorrhea.—Subacute
ovaritis of twelve years' duration relieved in 18 days.
Miss D., aged 30; nervo-sanguine temperament. She has always been irregular,
and when menstruation takes place the pains are agonizing. It is not infrequent that
she subsides into an unconscious state after the pains lessen, unless stimulants of
various kinds are used. There is an irritable bladder. Both ovaries are sensitive on
278
A TEXT-BOOK OF GYNECOLOGY.
pressure; the left one is constantly painful, and is perceptibly enlarged. Gave a
suppository of Guiac. morning and evening. Relief was experienced in five days
and 36 suppositories gave permanent relief.-M. O. Terry, M. D.
CASE XXXVI.-Dysmenorrhea and Spinal Irritation for years.
Ovaritis of two years' duration cured in 18 days with Guiacum.
Subacute
Miss H., aged 24; nervo-bilious temperament. She has constant pain between
the shoulders; fulness in the head, accompanied frequently with pain; suffers from
stomach derangement and dysmenorrhea. The first five of the dorsal vertebræ, the
coccyx, and two inches above it, are sensitive on pressure. There is a dull, aching
pain in the left ovary, which has continued over two years.
I will not give the names of the "indicated" remedies which were tried and
found wanting in her case.
The pains across the shoulders, fulness in the head, and nausea, disappeared after
a few applications of Paquelin's thermo-cautery had been made to the sensitive ver-
tebræ.
Other remedies having failed in the ovarian pain, Guaiac. suppositories, 36 in
number, given as in the other cases, entirely eradicated it.—M. O. Terry, M. D., New
York Transactions, 1883.
CASES SHOWING THE BENEFICIAL EFFECTS OF DIVULSION IN DYSMENORRHEA.
CASE XXXVII.-M., æt. 26, very tall but well proportioned. Upon presenting herself
to me she gave the following history: Began to menstruate at 13, and became regular
at 15; more or less dysmenorrhea from the first, and the amount of blood lost has
always been excessive. Says that she does not remember when she did not have cold
hands and feet. However, she got on very well until entering college, when the hard
mental work, together with the exposure and "stair-climbing" incident to her college
course, completely prostrated her. The symptoms of obstructive dysmenorrhea kept
her in bed during the entire sick week; she became greatly depressed and melan-
cholic-so much so that her room-mate feared suicide; subject to frequent attacks of
palpitation with syncope; the bowels remained obstinately constipated in spite of
the best directed general and therapeutic measures, and the digestion became
bad. The amount of blood lost was excessive and the resulting anemia was marked.
On July 15 the cervix and rectum were divulsed in the manner heretofore noted,
the
uterus curetted and the patient left in care of Dr. Luten of Grand Rapids. She re-
mained in bed for ten days, when the plug was removed and she was permitted to
get up. Notwithstanding the fact that she began the arduous duties of a teacher
four weeks later, the improvement was of the most marked character. Six months
from the time of the opera'ion she walked into my office looking the picture of
health. To use her own words, she said: "I have never before known what it was to
be luxuriously well." Menstruation from the very
Menstruation from the very first period following the operation
was painless and the first premonition of its oncoming is the appearance of the flow.
The nervousness and mental depression have entirely vanished, the hands and feet
have become warm, the digestion is markedly improved and the bowels are perfectly
regular.
CASE XXXVIII.-M., æt. 21, referred to me by Prof. D. A. McLachlan, because of
some obscure eye trouble which failed to yield to measures directed to the eye, and
MENSTRUATION AND ITS DISORDERS.
279
which, from the symptoms complained of, led him to believe that pelvic complications
were responsible for much of the difficulty. This patient, so far as physical develop-
ment is concerned, is an ideal specimen of womanhood, and yet three days of each
month were characterized by intense dysmenorrheal pains with all the phenomena
of obstruction. Obstinate constipation was the only disturbance of the gastro-in-
testinal canal, and there were no prominent nervous symptoms. Menstruation was
scant rather than excessive. The uterus was anteflexed, and the external os of the
"pin-hole" type; it was with much difficulty that a fine probe could be made to in-
sinuate itself through the internal opening, though there was not the usual sensitive-
ness at this point, a fact which explains the absence of many of the nervous symp-
toms described in the preceding case.
In spite of my best directed treatment I could do nothing more than palliate the
dysmenorrheal symptoms. Gelsemium did much good during the attack, and the grad-
uated sounds introduced just before the advent of the flow would cause the succeed-
ing period to be much less painful; but the improvement, notwithstanding a three months
course of local and general treatment, was only temporary, and after an interval of
two months the dysmenorrhea became quite as bad as before the treatment. Ac-
cordingly on December 23, 1890, I divulsed, under ether, both the cervix and the
rectum, operating upon the latter because of the constipation. The patient men-
struated at the succeeding period with absolutely no pain, and up to the present time
(July 1893) remains almost entirely free from suffering during the menstrual
week. Her constipation, while not absolutely cured, is infinitely better, and with the
least care in diet gives her no trouble. The eye symptoms are likewise much bene-
fited though not entirely relieved. I have in another place remarked upon the ob-
stinacy of the ocular neuroses; * when due to pelvic lesions they are usually the last
to disappear when such lesions have been cured, and indeed, often will not yield to
any treatment.
The foregoing cases illustrate in a general way the benefit
to be derived from divulsion when indicated. I am sorry that I
have not kept an accurate record of all of the cases operated upon
by me. I have kept track of all private, as well as most hospital
patients, and, with the exception of the two cases already referred
to, the results have been universally satisfactory. These two
cases were operated upon eight years ago, and each suffered
from a sharp attack of pelvic peritonitis as a result. Neither
case was suitable for the operation, and at that time I had not
mastered the principles of antisepsis. In trachelorrhaphy I
divulse, in the majority of cases, at the time of operating, and
have seen nothing but good result from the practice.
* v, page 190.
CHAPTER XIX.
MENOPAUSE.
Definition. This term is applied to that time of life when
the function of menstruation is permanently suspended. It is
known, also, as the change of life, the critical time, the turn of
life, and the climacteric period. The age at which the meno-
pause occurs is most variable. Cases are on record in which
menstruation was permanently suspended at thirty-two, and Dr.
T. A. Emmet has reported a case in which the function recurred
regularly, although the woman was seventy-two years old.
These ages are the extremes, the climacteric changes being
inaugurated in the larger number of cases at about forty-five.
Such extremes may be due either to idiosyncrasy, to rapid child-
bearing, or to some constitutional disease. Thus, there are
certain families in which the climacteric period occurs early, or,
it may be, late in life. Rapid child-bearing has a tendency, by
depressing the system, to hasten the change; and constitutional
diseases may either precipitate or prolong the menopause, as
they may precipitate or delay puberty.
There is a popular error, which is by no means limited to the
laity, that it is necessary for a woman to undergo a certain
amount of suffering while passing through this period. Much
harm has resulted from this erroneous impression. A woman,
perfectly healthy in all respects, should not suffer inconvenience;
nevertheless, there are very few instances where the change of
life is passed through without more or less discomfort. If,
however, the function of menstruation has been perfectly normal,
if there exists no local or constitutional disease, in short, if a
woman is perfectly healthy, the climacteric change should
come to her as a pleasant advent rather than one of suf-
fering.
The doctrine of necessary suffering at this time, and especially
280
MENOPAUSE.
281
the doctrine that it is perfectly natural for excessive menstruation
and metrorrhagia to take place, has more than once led to the
neglect of various affections which are responsible for the delayed
cessation. Thus, cancer, fibroid tumors, fungoid degeneration of
the endometrium, and polypi are permitted to progress indefi-
nitely, the woman continuing to flow long after ovulation has
ceased. Usually, when menstruation is prolonged after the age
of fifty, it is because of local disease, and a thorough examina-
tion should be instituted.
Anatomical Changes.-The anatomical changes contrast
markedly with those occurring at puberty. Thus, the vascularity
of all the pelvic organs is increased at puberty; whereas the
vascularity is diminished after the menopause. Physiological
hypertrophy of these organs characterizes puberty; physiolog-
ical atrophy is instituted by the menopause. The ovaries
become smaller and in time are converted into contracted
masses of fibrous and cellular tissue; the Graafian follicles
shrivel and contract. Like changes take place in the Fallopian
tubes, the uterus and the vagina. Indeed, all of the sexual
organs undergo senile atrophy and are reduced to a rudimentary
state.
This rearrangement may take place suddenly or gradually,
requiring much more time in some women than others. During
its progress the line of demarcation between the physiological
and pathological may be very hard to define.
Symptoms. As already stated, no distressing symptoms
should attend the menopause if the patient is in a perfectly
healthy condition; but, as there are few women absolutely free
from distress during the menstrual period, though this function
should be perfectly painless, so there are few women absolutely
free from discomfort while the system is undergoing climacteric
changes. The degree of suffering will, however, depend, in no
small measure, upon the temperament of the patient, a nervous
woman suffering infinitely more than one of phlegmatic tem-
perament.
The character of the symptoms will also depend upon the
habit of the patient. If she be plethoric, for instance, the phe-
nomena will be those attending plethora,-congestion of various
282
A TEXT-BOOK OF GYNECOLOGY.
parts of the body, headache, palpitation, hemorrhages, etc.; if
chlorotic or anemic, she will suffer from the symptoms in-
cident to the depravity of nutrition.
Headaches are of frequent occurrence and may be either con-
gestive or anemic in character. The disturbance of the vaso-
motor system gives rise to flushings and an irregular distribution
of blood to various parts of the body. Alternate coldness and
heat of the hands and feet are likewise of common occurrence.
There may be either irritability, or torpor and sluggishness, of
the gastro-intestinal canal. If irritability, there is often nausea,
vomiting, and diarrhea, the result of a hyperesthetic condition
of the mucous membrane. One of the worst cases of irritable
rectum with which I have ever met occurred during the
climacteric period. If there be sensory paralysis of the mucous
membrane, the most obstinate constipation may ensue.
Flatu-
lence is likewise a frequent result of the gastro-intestinal dis-
turbance. So great is the accumulation of gas at times that
pregnancy is suspected. Indeed, all of the subjective symptoms
of pregnancy may be so faithfully imitated as to make the diag-
nosis extremely uncertain.
The
The processes of elimination are more active in every way.
skin eliminates more readily, and perspirations, at times morbid,
often occur. All of the salts of the urine, especially the urea,
are in excess. The quantity of carbonic acid eliminated is also
increased. Very often, too, the secretions of all of the mucous
membranes, particularly those of the genital tract, are exaggera-
ted. Occasionally vicarious leucorrhea will continue, becoming
increased at certain intervals, for a long time after the last
appearance of the flow. Let it not be forgotten, however, that
a leucorrhea more or less persistent is usually the result of local
disease, and when it does not abate in due time an examination
should not be too long delayed. The first symptom of carcinoma
may be a leucorrheal discharge, and since the patient is passing
through the so-called cancerous age, any suspicious symptoms
should be carefully investigated.
The nervous symptoms not infrequently predominate, though
the patient may not suffer from an excessive loss of blood.
Indeed, they often persist after menstruation has ceased entirely,
MENOPAUSE.
283
and when the local evidences of disease, so far as tissue changes
are concerned, are wanting. Dr. Wylie has called attention to
the fact that there often exists, in these seemingly obscure cases,
a hyperesthetic spot at the internal os, or at some portion of the
fundal mucous membrane. I have frequently demonstrated the
presence of this hyperesthetic spot, not only in women passing
through the change of life, but in young girls victims of dys-
menorrhea. A sound passed into the uterine cavity will give
rise to the most exquisite pain when it comes in contact with
it; and I have had patients nearly jump from the examining table
when the tender point was touched. I remember one case in
particular, in which I could produce a most intense supraorbital
neuralgia by passing the sound. The cause of the hyperes-
thesia is uncertain, though it is probable, as suggested by
Wylie, that it is the result of previous inflammation. The fact
that this localized hyperesthesia is productive of innumerable
reflex symptoms is clearly proved by the effects of treatment:
when the diseased area is destroyed, the symptoms will frequently
vanish as if by magic.
The changes attending the menopause are indeed critical in
character, and the patient's future health will depend, in no small
degree, upon the care which she receives while passing through
this period. Many existing diseases will entirely disappear.
This is especially true of the various chronic inflammatory affec-
tions. Indeed, metritis may be incurable so long as menstrua-
tion recurs at each month to excite congestion. The various
inflammatory affections of the ovaries are likewise often incura-
ble while the function of ovulation continues; and of course the
different forms of menstrual irregularities disappear with the
cessation of ovulation. Fibroid tumors usually stop growing
after the change of life, and often undergo a more or less decided
atrophy.
On the other hand, certain other diseases are either aggravated
or precipitated by the climacteric changes. As already intimated,
the several forms of cancer make their appearance at this time
oftener than at any other. Nervous affections of various kinds
frequently date from this period. Hysteria, epilepsy, paralyses,
apoplexy, and especially insanity, are often fanned into existence
"
284
A TEXT-BOOK OF GYNECOLOGY.
by the conditions attending the change of life. As suggested by
Ludlam, there is a tendency for diseases which existed when
the function of menstruation was inaugurated, and which were
held in abeyance by it, to recur at the cessation of the function.
Such diseases are the various skin and bowel affections, tuber-
culosis, and the neuroses. Skin affections are particularly liable
to be brought to the surface, and a careful inquiry into the clini-
cal history will frequently reveal the fact that the patient suffered
from the same affection during girlhood.
In conclusion, then, a woman should pass through the meno-
pause, if perfectly well, without serious inconvenience. When
the system is greatly disturbed, it means that something is
wrong. The disturbing cause may or may not require for its
removal local measures. The inconvenience may be so slight as
hardly to overstep the boundary of the normal, and no attention
other than perhaps a little general advice need be given the case.
On the other hand, if the patient suffers unduly, there is no
period of her life during which she more needs judicious care
and treatment.
Treatment. There are certain general hygienic principles
which are applicable in all cases. The frequent use of the sponge
bath will keep the skin active and promote elimination. At least
twice a week the patient should take a hot bath, remaining in
the water for from twenty to thirty minutes. After either the
sponge or the tub bath, the skin should be well rubbed down
with a Turkish towel.
The amount of physical exercise to be prescribed in a given
case must depend upon circumstances. Plethoric patients are
nearly always benefited by outdoor exercise, short of fatigue
-weariness or exhaustion is always injurious. Where there is
marked debility, walking, or, indeed, any form of exercise, may
be impossible. The muscular system should, however, receive
attention, and if the patient finds it difficult to walk, massage
may be advantageously substituted.
Late hours, especially in nervous cases, should be avoided.
Insomnia is often a prominent symptom and every precaution
should be taken to promote sleep. Plenty of fresh air is the
best natural soporific and the sleeping apartments should, there-
MENOPAUSE.
285
fore, be well ventilated. Excitement during the evening is most
injurious. Many times a warm bath or a hot vaginal douche
immediately before retiring, will afford a good night's sleep.
Tilt maintains that thin, nervous women cannot sleep too much.
He recommends, when insomnia is very troublesome, that the
patient eat immediately before retiring, or have at her bedside
some light broth or bouillon to take during the night.
Sexual hygiene is likewise of much importance. Intercourse
should take place only at long intervals. When there is an in-
crease in the sexual appetite it means, in a large majority of cases,
that there is some local disease which requires attention. Tilt
emphasizes the fact that women passing through the climacteric
period should not marry. He cites several cases coming under
his own observation where the most disastrous consequences
followed immediately upon marriage.
Much tact is often required in the management of the mental .
and moral symptoms. There is, many times, a marked perver-
sion in the moral sensibilities. Women previously cheerful and
contented become irritable, taciturn and unreasonable. It may
be necessary to remove a woman thus affected from home sur-
roundings. A change of scenery, association, and climate is
often most beneficial.
As regards local treatment, any of the various lesions which
have been enumerated should, if present, be removed. The
treatment of the hyperesthetic spot, when it exists, consists of
the application of a ten per cent. solution of cocain directly to
the parts, followed by the introduction of a hard steel dilator and
a moderate degree of divulsion. Pure carbolic acid is then ap-
plied to the endometrium, after which a boro-glycerid tampon is
introduced into the vagina. It is surprising how quickly this
treatment will relieve many of the reflex nervous symptoms.
hemorrhage is a prominent symptom the uterine cavity should
be carefully explored and, if necessary, the curette applied.
Finally, lesions of the rectum should always be looked for. It
is my practice to divulse the rectum also when the cervix is
forcibly divulsed for the purpose of relieving nervous symptoms.
If
I know of no class of symptoms which will respond more
quickly to the properly selected remedy than will the various
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A TEXT-BOOK OF GYNECOLOGY.
disturbances and phenomena incident to the menopause. It is to
me most surprising that the specialists of the older school have
never learned to use intelligently, at least some of the remedies
which the homeopathic school find so useful in relieving the
innumerable phenomena characterizing this period. Ringer,
Bartholow and others have hinted at the utility of many of
them in the condition under consideration, but the specialists
have largely ignored the suggestions of these writers. They con-
fess their inability to relieve the flushes, the headaches, the local
congestions, etc., without placing the patient under the action of
remedies the continuous use of which they themselves admit to
be pernicious. At the same time I desire to insist upon the
necessity of looking for local causes when the internal remedy
'fails to relieve the symptoms for which it is prescribed. If
selected with care it will do all that it is possible for internal
medication to accomplish, and when it fails in its object it is
usually because of the existence of some local or mechanical
cause which requires for its eradication local or mechanical
measures.
Therapeutics.
Sanguinaria.—There is much irritability and anger; head-
ache begins in the occiput, extends upward and settles over the right
eye; distention of the veins of the face with excessive redness,
or circumscribed redness of one or both cheeks; FLUSHINGS, lassi-
tude, torpor and langour; not disposed to move or make any
mental exertion; symptoms all aggravated during damp
weather.
Lachesis. Chills at night and flushes of heat during the
day; patient feels much depressed in early morning; MUCH heat
AT THE VERTEX; globus hystericus with great sensitiveness of the
larynx; SYMPTOMS worse after sleep.
Sulphur.-Flushes of heat followed by cold spells; cold feet;
bleeding hemorrhoids; constitutional bias prominent.
Pulsatilla.-Tearful temperament; shooting neuralgic pains
in various parts of the body; milky, thick leucorrhea with
swollen vulva; pressure in pit of stomach after every meal, with
vomiting of food; all symptoms relieved in open air.
MENOPAUSE.
287
Jaborandi.-MORBID PERSPIRATIONS; MARKED SALIVATION;
suffusion of the face and the entire body; nausea and vomiting.
Sepia.—ALL GONE, SINKING SENSATION AT PIT OF STOMACH;
moth-colored spots on the skin, especially on forehead and over
bridge of nose; unnatural perspirations, particularly in axillæ ;
anemia from profuse menstruation; leucorrhea yellowish or
greenish and causing much itching; hysterical twitchings and
spasms.
Amyl nitrite. This remedy is, I believe, one of the most
useful of all remedies in the flushes of heat so often present
during the climaxis. They are attended by throbbing and a
sensation of intense fullness in the head; there is often a
choking, restricted feeling about the throat which lachesis fails
to relieve; much throbbing in the ears.
Glonoin. Congestion about the head with much FULLNESS
AND THROBBING; flushes of heat with vertigo; alternate redness
and paleness of face; symptoms all aggravated in a warm room
and ameliorated by walking in the cold air; frequent attacks of
fainting.
Ignatia.-Desire to be alone; changeable disposition, though
sadness predominates; clavus hystericus; throbbing pain in the
occiput.
Consult:-Aconite, caulophyllum, cimicifuga, belladonna,
gelsemium, argentum nit., and coffea.
Illustrative Cases.
CASE XXXIX.-Reflex Nervous Symptoms Cured by Divulsion and the Applica-
tion of Carbolic Acid.—In the spring of 1880, a rather thin, wiry woman was sent to me
by Dr. Greenough, of this city. She said that she had dysmenorrhea when young, but
had not had any special uterine disease that she was aware of. She had married when
thirty, and about five years later her menstruation had ceased, and had not shown
itself, except two or three times when she had a scanty flow, for the past two years,
and that during this time she had had hot flashes and all kinds of nervous symptoms,
had taken all kinds of remedies, but that she was growing thin, sleepless, etc., and
that Dr. G. advised her to have a local examination. I found the vagina and uterine
appendages normal, so far as I could discover; the uterus was a little below the
normal size, but not as small as is usual two years after the menopause. It was ante-
flexed and in about the normal position. In and near the os the mucous membrane
had a peculiar coppery or yellowish-stained appearance, which I had now and then
seen about the cervix uteri of women past the menopause. In passing a sound I
288
A TEXT-BOOK OF GYNECOLOGY.
found the os internum contracted, and as the sound passed into the cavity of the
fundus it gave exquisite pain, and reminded me so forcibly of the condition of the
uterus so very common in young women suffering from dysmenorrhea due to imper-
fect development that I made up my mind to give it the same treatment as I was then
using for the relief of dysmenorrhea. I gave the usual preparatory treatment, and
dilated the cervix with a steel dilator, and applied, by means of an applicator and
cervical protector, pure carbolic acid to the endometrium. I warned her, as I do in
cases of dysmenorrhea, that the first dilatation might be quite painful and increase
her nervousness for a day or so, but that the second would not be so painful, and the
third still less so, and that if this treatment helped her I could probably cure her. The
dilatations were made about a week apart. The result was magical; her nervous
system quieted down, she could sleep, eat well, and she steadily improved in general
health. Twice within six months she had a slight return of the reflex symptoms, and
the dilatation and applications were repeated with equally good results. In a year's
time she had gained twenty-six pounds in weight, and claimed to be perfectly well.
Since then I have treated a large number of cases suffering from reflex nervousness
at and soon after the menopause, by dilatation and applications, and with most excel-
lent success.
In two or three of these cases the nervousness was extreme, and the
patients had been through all kinds of treatment in the way of medication, water
cures, and even "rest cures," without permanent relief; yet they were cured in a very
short time by dilatation and intra-uterine applications.—Wylie.
CASE XL.-Dipsomania.-Like B. de Boismont, I have several times seen tem-
perate women have a craving for spirits only at the menstrual epochs, the craving
subsiding with the flow; and the same desire has been noticed in pregnant and puer-
peral women. Esquirol and H. Royer-Collard have met with women in good circum-
stances, who all through life had been temperate, but who at the change were sud-
denly seized with an irresistible desire for brandy, which again became disagreeable
to them when the critical period was passed. This impulse is akin to the well known
longings of pregnancy, and those who yield to it know that they are doing wrong,
struggle against it, but are sometimes overcome. It is easy to understand how such
impulses should be rife at all the periods when the ganglionic nervous system is in a
state of perturbation, and when anomalous sensations at the epigastric region indicate
morbid action in the central ganglia. It can be cured by proper treatment.— Tilt.
CASE XLI.—Kleptomania.—Drs. Taylor and Marc have known patients who, pre-
vious to puberty or to disordered menstruation, were conscientious respecters of rights of
property, but who, though in affluence, would steal, at all risks, at the critical periods.
of life. Dr. Marc mentions a rich lady who, during pregnancy, could not resist the
temptation of stealing a chicken from a cook shop. I have already described cases
of this description caused by the change of life, and I believe they are of more
frequent occurrence than is supposed, although the sense of acting wrongly is still
present to the mind of those who yield to this impulse.-Tilt.
CASE XLII.-Nervous Aphonia.—This is a rare affection, but I have had a good
opportunity for studying the case of a lady, at the change of life, who, after losing her
husband, came to town and settled in Belgravia. Though she had not been hitherto
subject to nervous affections cold, over-exertion, or worry, would suddenly deprive
her of her voice for a few days, and this sometimes occurred without apparent cause.
MENOPAUSE.
289
The nervous nature of the ailment was shown by the sudden coming and leaving of
the aphonia, and by the effect of change of air; for a drive in Regent's Park or to
Hampstead would often restore her voice to its natural tone. On leaving town to
reside in the country, she has ever since enjoyed a comparative immunity from this
complaint. Sometimes a potion containing ether speedily dispelled the aphonia. In
two cases I found sudorifics useful, the permanent return of the voice coinciding with
a marked determination to the skin. Cerise speaks in favor of emetics for nervous
aphonia, and I have witnessed their sudden good effects, but the best treatment is the
direct application of electro-magnetism, either to the tongue or to the larynx, by means
of Dr. Morrell Mackenzie's galvanizer. The shock makes the patient scream, the
spell is broken, and she is immediately cured.— Tilt.
CASE XLIII.—The Menopause Delayed by Fungosities of the Endometrium.—This
patient was married, and the mother of five children. After the birth of her last child
she suffered from uterine leucorrhea, probably caused by endometritis. She had fair
health in spite of that, and menstruated regularly until she was forty-six years old, and
then the menstrual flow became more profuse. This continued intermittently for nearly
one year, when the menses came more frequently, lasted longer, and the flow was
quite profuse. Her health failed gradually; she became anemic, weak, low-spirited,
and nervous. Though her flesh remained (she was rather stout), her strength was
greatly reduced. Her family physician gave her the usual remedies-lead and opium,
ergot, cannabis indica, and aromatic sulphuric acid-in the hope of controlling the
flow, but without effect.
Finally, she consented, with some reluctance, to an examination, when a large
number of polypoid growths were found in the cavity of the uterus. These were
removed with the curette, and the flow stopped for six weeks; it then returned for
a few days, but was not very free. There was a return of the menstrual flow in two
months, very scanty, and another in three months, and that was the end of it. She
was then forty-eight years old. After the removal of the fungous growths with the
curette, her health improved under tonic treatment, and, when last seen, at forty-nine
years of age, she was quite well.—Skene.
CASE XLIV.-Diarrhea and Morbid Perspirations.-Catherine M., aged fifty-three,
tall, thin, and pale, menstruated very abundantly at fifteen years of age; was regular from
the first, and continued so for three or four days every three or four weeks, with so
little suffering that "she never felt them come or go." She married at thirty-three,
miscarried three times, and bore five children, the last at forty-seven; and menstrua-
tion, which had been irregular a year previous to conception, never returned after that
event. The patient was generally relaxed during the menstrual epochs, and during
her last pregnancy, and after her confinement, she frequently had three or four stools
a day, without pain or loss of appetite, after which diarrhea came on every three or
four weeks, with flushes and drenching perspirations. For the last twelve months
she was relieved six or seven times a day, until lately, when the bowels only acted
once in two days, and on this account she had suffered much from heat, flatus, nausea,
oppression at the pit of the stomach, and want of appetite, although her tongue was
clean and healthy. When the action of the bowels became freer, the patient got
well.- Tilt.
19
CHAPTER XX.
VICARIOUS MENSTRUATION.
Definition and Synonyms.-The term vicarious menstrua-
tion is applied to the discharge of menstrual blood through some
channel other than the uterus. Flamant uses to define this con-
dition the word xenomania, which expresses "the idea of the
menses taking a wrong course." Barnes proposes, when the
menses escape from the wrong place, the term ectopic menstrua-
tion. Finally, Dr. Bedford-Fenwick suggests that the term vicar-
ious hemorrhage more clearly defines the phenomenon than does
that of vicarious menstruation, because the vicarious discharges
do not possess the characteristics of true menstrual blood.
The dearth of modern literature bearing upon the subject is
something surprising. Gendren, Parrot, Whitehead, and Courty,
of the older authors, deal with it somewhat in detail and have
recorded several cases of so-called vicarious menstruation, some
of which will hardly stand the test of modern scientific investi-
gation. More recent and reliable ones are recorded by Butler,§
Rein,§ Chapman,§ Hardon,§ Cooper,§ Barnes,* Routh,* Fen-
wick,* Mansell-Moullin,* Mitchell,† M. Guépin, and many
other writers. Some of these cases are referred to in detail at
the end of this chapter.
By far the most learned and scientific dissertation yet pro-
duced in any language treating of vicarious menstruation was
presented in 1886 to the British Gynecological Society, by Robert
Barnes, m. d., F. R. C. P., and published in the Transactions of
that year. The discussion that followed was equally learned,
making with the essay a most valuable and elaborate contribu-
* British Gynecological Journal, Vol. 11.
† American Journal of Medical Sciences, Vol. xxx, p. 83.
† Medical Times and Gazette, 1862, p. 338.
? Annual of Universal Medical Sciences, 1889.
290
VICARIOUS MENSTRUATION.
291
tion to the literature of the subject. I shall in this chapter
endeavor to reflect the views of the justly celebrated essayist,
giving his conclusions in full.
Barnes was prompted to collect the data therein given for the
reason that Dr. Wilks, a writer equally sagacious, disputed most
emphatically and energetically the existence of so-called vicari-
ous menstruation. The former's arguments are so largely based
upon physiological and pathological phenomena and analogies,
which at times require most careful study in order to compre-
hend the author's meaning, as to prompt me to create from
them the following schema. This will be sufficiently amplified
to make it clear, and will, I think, aid the reader very materially
in following the arguments set forth :—
VICARIOUS MENSTRUATION.
I. Phenomena of normal menstruation, .
II. Analogy between menstruation and
pregnancy,
•
•
•
(a) Increased nervous tension and mo-
bility;
(b) Increased vascular tension;
(c) Increased temperature;
(d) Increased excretion of urea.
(a) Ovulation the beginning of both;
(6) Mucous membrane-similar changes
in both;
(c) Exalted nervous tension-present
in both;
(d) Casting off of useless decidua in
menstruation is analogous to
labor.
The object of normal menstruation is, therefore, to discharge superfluous material
and energy not required for gestation.
III. Physiological substitutes for menstru-
ation,
•
•
IV. Pathological substitutes for menstru-
ation,
•
V. Theories, .
(a) Pregnancy-hence a form of vicari-
ous menstruation;
(6) Lactation—hence a form of vicari-
ous menstruation;
(c) Building up of new tissue.
(a) Vicarious diarrhea or leucorrhea;
(6) Serous effusions;
(c) Ectopic, or vicarious discharge of
blood.
((a) Plethoric-increased intra-vascular pressure.
(b) Neurotic-
proofs,
(c) Becquerel's and
Scanzoni's theory,
Influence of the emotions upon
menstruation;
(2) Influence of nervous system upon
the circulation;
(3) Frequency of vicarious menstrua-
tion in neurotic subjects.
Abnormal structure of the vessels and
organs to which the flux is directed.
292
A TEXT-BOOK OF GYNECOLOGY.
Dr. Barnes says: "We are met at the outset by this difficulty:
physiologists are not agreed as to what causes or constitutes
normal menstruation. This difficulty may be evaded without
seriously affecting the argument, by putting aside the controversy
as to whether the menstrual flux is caused by the maturation
of the ovules. My own observation inclines strongly to the
conclusion that ovulation is the immediate cause of the flux. * *
Briefly, then, menstruation consists in the periodical discharge
of blood from the uterus. This, the most conspicuous objective
phenomenon, is, however, only one act in a complicated process,
of which the genital system is the focus, but upon which the
entire organism is at work.”
by
The phenomena of normal menstruation are—
I. Increased nervous tension and mobility.-This is evidenced
"exalted psychical, emotional, and reflex action."
2. Increased vascular tension.—This gives rise to “turgescence
of the capillary and venous systems," as is demonstrable by the
sphygmograph. "The vascular tension falls quickly when the
menstrual blood-flow sets in."*
3. Increased temperature.-Repeated observation shows that
the temperature is increased before and during the menstrual
flow at least .5°. The urea is also increased.
The writer next draws a most ingenious analogy between
menstruation and pregnancy. He says:-"Assuming that the
primum mobile in either case resides in the ovary; the first step
is ovulation, or the ripening of an ovum and the depositing of
it in the uterus. But the work of preparation begins in the uterus
long before the extrusion of the ovule from the ovary. In
response to the development of the ovum, nerve force and blood
are attracted to the uterus, the whole organ swells, becomes
heavier and more sensitive, softer, from the permeation of its
walls by fluid; the utricular glands of its cavity enlarge, secrete
"The volume of blood is also increased. Andral and Gavarret showed that the
quantity of carbonic acid exhaled by the lungs rises until the age of thirty in men,
but only until puberty in women; moreover, that in women it falls off as soon as men-
struation is established, to increase again after the menopause. If for any cause the
menstrual flow is arrested for several months, as by pregnancy or lactation, the quan-
tity of carbonic acid is increased, as after the menopause.”—Barnes.
VICARIOUS MENSTRUATION.
293
more freely; the mucous membrane swells, grows, is developed
into a thick, soft, pulpy membrane, the decidua. This process
is the representation-to this point-of pregnancy. It is marked
by certain signs, more or less distinct, in different cases. But in
all there may be observed exalted nerve-tension, expressed by
greater emotional and reflex mobility, sometimes revealed in
neuralgia, in vomiting, and even convulsions. There is increased
central nervous irritability, and there is the eccentric source of
irritation in the uterus. Concurrently, there is observed a marked
increase of vascular tension. The pelvic vascular region espec-
ially feels the attractive force of the uterus. Then there comes
a casting-off and casting-out of the useless decidua ; the process
is traumatic. This is the analogue of labor. The developed
muscular fibers contract under the influence of the intensified
diastaltic function. Hemorrhage attends. The mimic labor over,
the blood-current and nerve energy are lowered, and the excess
diverted from the pelvis, and for a time the ordinary equilib-
rium of the economy is restored. The uterus returns to its
wonted state, and the breasts become quiescent. This history
presents points of similitude with that of gestation at every
stage."
Certainly the analogy between the two processes is traceable
in detail and without any great stretch of the imagination.
Ovulation has for its final object conception. If this does not
take place then menstruation occurs as a substitute for both con-
ception and parturition, during the last stage of which may be
seen the analogue of puerpera; the energy and material pre-
pared for the missed pregnancy is now superfluous and is dis-
charged.
Since, then, the object of menstruation is the discharge of
superfluous material and energy," it necessarily follows that
when the function is held in abeyance by physiological causes
there must be physiological substitutes for menstruation. The
causes which physiologically suspend the function are pregnancy
and lactation. During gestation the blood which would be lost in
the menstrual discharge, were menstruation not interrupted by
pregnancy, is used for structural purposes in the development of
the fetus. Lactation is likewise a substitute for menstruation,
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for, commonly, menstruation is suspended during the usual
period of lactation. A third substitute for menstruation is the
building up of new tissue. This is why women so frequently be-
come fleshy after the menopause. The material elaborated for
menstruation is no longer needed for that purpose; nor can it
be utilized for either gestation or lactation-hence the general
deposition of fat.
It must be observed, in passing, that neither pregnancy nor
lactation always suspends menstruation. For some reason ovu-
lation (I assume that ovulation is the primum mobile of menstrua-
tion) is not interrupted by gestation; or recurs during lactation.
In this way true menstruation, i. e., a periodical discharge of
blood from the uterine cavity, takes place, which differs in no
wise from true menstrual discharge. For the first three months
of gestation this is entirely explicable, for the decidual cavity is
not always perfectly closed. Of course, it is not difficult to un-
derstand the processes of menstruation during lactation; the
uterine mucosa has returned to its normal state and, if the men-
strual wave is set in motion by ovulation, it is ready to undergo
the changes incident to menstruation. Hemorrhage occurring
at these periods, however, does not always proceed from the
uterine cavity. It may come from the vagina or the cervical
canal—the tendency to an overflow from some point being too
strong to be restrained. Barnes records one case in which the
villi of the vaginal portion were bared, tumid, and vascular, so
that malignant disease was strongly suspected. The cervix re-
turned to its normal condition after labor. I have seen a case
very much like this, the patient menstruating regularly up to
the time of her miscarriage at the end of the fourth month.
Projecting from the posterior lip was a vascular growth as large
as a hickory nut, which a microscopical examination proved to
be simple hypertrophy of the mucous membrane. After the
miscarriage the hypertrophied tissue entirely disappeared.
"These hemorrhages," says Barnes, "are conservative in de-
sign. *
* They relieve systemic and local hyperemia.
In this respect they resemble some cases of abortion, which
may be regarded as a protest of nature against the continuance
of a dangerous pregnancy; unless relief be found in this way,
* *
VICARIOUS MENSTRUATION.
295
vital organs may be struck, and we may have fatal cerebral or
lung apoplexy."
I will now allude to the evidence which justifies a belief in the
existence of vicarious menstruation.
I. Clinical observation.-Not all of the cases recorded by Barnes
and other writers will bear close investigation, but there is, I
believe, sufficient reliable clinical evidence to convince any
unprejudiced investigator that vicarious hemorrhages do occur.
2. A profuse hemorrhage from distant organs frequently causes
catamenial suppression.-This shows the part played by increased
vascular tension, which characterizes normal menstruation. If
this tension is relieved by an escape of blood from any part of
the body remote from the uterus it may suspend, temporarily,
menstruation-in fact, is a substitute for menstruation.
3. The various organs of the body are constantly assuming vica-
rious or supplementary functions.-I again quote in detail from
Barnes: "The skin, the kidneys, the lungs, the liver, the glan-
dular system, intestinal and other, are constantly doing recipro-
cal work. That obstructed or arrested menstruation, then,
should be supplemented or helped by other organs than the
uterus is in strict accordance with the fundamental laws of phy-
siology. There is a solidarity in the organism, binding the con-
stituent organs into unity, and making them work with one con-
sent. Reasoning from this basis we shall be prepared to under-
stand that menstruation is not simply a function of the uterus
and ovaries, but a systemic function.
Menstruation, or
an equivalent substitute, must be performed."
We have seen that the physiological substitutes for menstrua-
tion are pregnancy, lactation, and the building up of new tissue.
If the material elaborated for these several purposes is not util-
ized for the same; or, if it is not discharged as superfluous in the
form of menstruation, we may expect a more or less successful
attempt at one or more of the following pathological substitutes:
1. A vicarious diarrhea or leucorrhea.-Both are usually very
watery, the leucorrhea consisting of serum or mucus.
2. Serous effusions.—These occur in the substance of organs,
in serous cavities, or in connective tissue. In chloro-anemic
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girls, anasarca, more or less general, is not of infrequent occur-
rence.
3. Ectopic or vicarious discharges of blood from any and every
part of the body.-The most common seat of the discharge is the
nose; next in frequency come the stomach and lungs. It may,
however, proceed from any part of the body, selecting by prefer-
ence, as we shall see later on, some site previously weakened by
disease.
Should the system not be relieved by the foregoing substitutes
there may arise any of the various neuroses, as neuralgia, migraine,
hysteria, epilepsy, apoplexy, etc. To classify these affections as
pathological substitutes for menstruation, as does Barnes, strikes
me as carrying the philosophy of analogy too far. They are
rather the sequelæ of an arrested function, and hardly come
within the range of either an analogue or a homologue of men-
struation.
I think that the arguments produced prove pretty conclusively
that menstruation, or its equivalent, must be performed, or the
system will bring into action reciprocal functions. It now
becomes necessary to analyze the various theories which have
been put forth as explanatory of vicarious menstruation. They
are the following:-
1. The Plethoric Theory.-This is one of the oldest, and is
based upon the well-known fact that intra-arterial pressure is
always increased before menstruation. It implies the necessity
of relief through some channel-if the usual avenue is closed,
vent is found at the locus minoris resistentiæ. Should the ordi-
nary safety-valves fail, and the blood find no external outlet, it
may escape, as we have seen, into the brain, the liver, the kid-
ney, the spleen, or, indeed, into and from any of the internal
organs.
Parrot objects to this theory upon the ground that most of
the victims of vicarious hemorrhage have been chlorotic, in
which affection the red blood-corpuscles are diminished-the
very reverse of true plethora. In refutation of Parrot's objection,
Barnes very appropriately remarks that "increased vascular
turgescence and exalted vascular pressure are phenomena found
VICARIOUS MENSTRUATION.
297
with diminution of the red globules." Such a state exists in
pregnancy, for instance, when the watery element of the blood
is increased with correspondingly increased peripheral vascular
tension.
2. The Neurotic Theory.-The chief champion of this theory
is Parrot, whom I have just quoted. Parrot has applied to these
hemorrhages the term "neuropathic." In support of this theory
it is adduced that menstruation may be suppressed by emotional
causes, as anger, fright, joy, etc., the suppression being frequently
followed by hematemesis; that the subjects of vicarious hemor-
rhage are nearly, if not quite, all victims of some nervous disor-
der; and, finally, that in those cases where the discharge continues
after the removal of such disorder, a habit induced by the period-
ical repetition is sufficient to perpetuate the menstrual escape of
blood. (Whitehead.)
The influence of the nervous system in the perversion of the
function of menstruation cannot be questioned. I have endeav-
ored to make this clear in the chapter devoted to the General
Pathology of Gynecological Diseases. That local hyperemia
and anemia may be induced by nervous influences is well shown
in the phenomena of blushing and the pallor of fear. The
nervous system exerts a controlling force upon the circulation
which, if suspended or diverted, may cause intense congestion
in some part or organ of the body, with resulting hemorrhage.
But, as observed by Barnes, "If we must admit the fact that the
blood could not move in the vessels unless under the influence
of nervous energy, we must equally admit that there would be
no nervous energy were it not for the nutrient and stimulant
energy of the blood." There is, therefore, a concurrent and
mutual action of both the vascular and nervous systems in nor-
mal menstruation, and vicarious menstruation is but a perversion
of physiology. The part played by congenital weakness and
abnormal structure will be considered under the caption of—
3. Becquerel's and Scanzoni's Theory.-It has been observed
that the seat of hemorrhage is frequently located in tissues
diseased or congenitally weak. Scanzoni especially emphasizes
the importance of abnormal structure of the vessels supplying
the organ from which the flux proceeds. Depaul and Guéinot
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(quoted by Barnes) remark "that the blood-flux usually
takes place in regions or tissues deprived of their natural tegu-
ment, that is, from wounds, ulcers, rupture of varicose veins,
etc." This has been my observation in several cases, though
there are many on record in which no such disease was present.
It must not be forgotten that the diseased tissues may be the
consequence rather than the cause of the ectopic discharge. If
it be true that increased intra-vascular pressure plays such a
prominent rôle in both normal and vicarious menstruation, it
seems not illogical to presume that the escape of blood is most
liable to occur at the point of least resistance. The flow gener-
ally continues to recur from the seat of election, and it may take
place from more than one point simultaneously.
None of the several factors, then, upon which the foregoing
theories-plethoric, neurotic, and local depravity of tissue-are
based can be ignored in studying the etiology of vicarious men-
struation. Some one element may be sufficiently conspicuous
in a given case to overshadow the other two; but a more care-
ful analysis will, in most instances at least, show a blending of
two or more of them, each of which plays a more or less impor-
tant rôle.
The conclusions given by Barnes are as follows:-
I. "That, as menstruation is a physiological necessity, so
when the function cannot be performed in the ordinary way
some substitute for it must be found, or mischief will ensue.
2. “Vicarious or supplementary functional action is a funda-
mental law in physiology. There is nothing exceptional in
vicarious menstruation.
<<
3. Vicarious menstruation may occur under various phases.
4. "It is conservative in intent and action, lessening or avert-
ing evil."
TREATMENT.
The therapeutical propositions set forth by Barnes cannot be
advantageously enlarged upon. They are in substance as
follows:-
I. The conditions which interfere with the proper discharge
of the menstrual blood should be removed.
2. Since vicarious menstruation is often associated with
VICARIOUS MENSTRUATION.
299
amenorrhea and dysmenorrhea the cause of these two symp-
toms should be sought for and removed. Mechanical obstruction
in some portion of the genital tract is a frequent cause, and such
obstruction should be overcome.
3. When the neurotic element predominates the nutritive
functions are usually disordered. Defective hematosis is of
frequent occurrence, and the functional derangement is often
marked. The depravity of nutrition may either precede or
follow the nervous disorder. The indications in either event
are to correct the constitutional bias.
4. If the vicarious discharge proceeds from an unhealthy sur-
face an attempt should be made to heal the morbid seat. An
effort should also be made to divert or attract the menstrual
nisus to the uterus, by: (a) Derivative or revulsive bleeding; (6)
local applications of iodin and the hot vaginal douche, electricity,
etc.; and (d) the internal administration of such remedies as
hamamelis, gossypium, digitalis, ergot, iodin, mercury, arsenic
etc.
Of the foregoing measures I would especially emphasize the
importance of electricity and the internal remedy. The method
of using electricity does not differ from that given in dealing
with amenorrhea. Negative cauterization in conjunction with
intra-uterine faradization, will, as I know from experience, do
much in the way of attracting blood to the uterus. I have, too,
great faith in the utility of the homeopathic remedy in setting
right the perverted function. It should, therefore, be selected
with care; an effort being made to find a drug whose action is
sufficiently profound to reach the constitutional derangements,
even though the word 'vicarious' does not appear in its
recorded pathogenesy.
Therapeutics.
Pulsatilla.—Particularly suitable to mild, tearful, yielding dis-
positions; pale face; difficulty in breathing after slight emo-
tions; morning sickness with bad taste in the mouth; no appetite;
vicarious hemorrhages in consequence of wet feet; epistaxis or
hematemesis following the suppression of menses; FEELS BET-
TER OUT OF DOORS.
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•
Bryonia.-Stitch-like pains in the lower abdomen aggravated by
the slightest motion, with tendency of blood to head; membran-
ous dysmenorrhea; frequent nosebleed when menses are sup-
pressed; in women accustomed to too early and too profuse
menstruation.
Ferrum.-ANEMIC WOMEN SUBJECT TO FIERY RED FLUSHING
OF THE FACE; menses appear with physical languor and mental
depression, unfitting her for work; hysterical symptoms after
menses.
Hamamelis.-Vicarious hemorrhages from nose, mouth,
stomach, or rectum, the blood being dark or venous in character;
VARICOSE VEINS OF LOWER EXTREMITIES.
Lachesis.-Evidences of blood degeneration; flashes of heat,
especially at the climacteric; coldness of feet; palpitation of
heart with feeling of constriction about the heart as if tightly held
in cords; oppression of the chest with dyspnea on wakening;
menses scanty but regular; desire for fresh air.
Digitalis. Dr. W. H. Hoyt reports a case cured by digitalis
characterized by the following symptoms: Pain in and about the
chest and sometimes epistaxis before the menses, followed by
choking spasmodic cough at night and expectoration of a solid
bloody mass with immediate relief. This mucus was very diffi-
cult to detach and presented a rusty black, clot-like appearance.
(Southwick.)
Kali carb.-Congestion of the brain and chest; hot flashes;
burning pain in region of hips; intermitting pulse; STITCHES IN
CHEST; heavy aching sensation in small of back during menses;
menses acrid, of a bad, pungent odor and excoriating; backache
and sticking pains in abdomen.
Ipecacuanha.—Menses too early and too profuse, blood bright
red; great weakness after menses; blue rings around eyes; dis-
tress in umbilical region; CONSTANT NAUSEA AND FAINTING.
Sanguinaria.-Scanty menstrual discharge with headache from
occiput to forehead as if the head would burst; eyes pressed out;
face red and hot.
Sabadilla.-The menses are suppressed immediately upon
their appearance, when they appear again sooner or later and are
again suppressed. (Guernsey.)
VICARIOUS MENSTRUATION.
301
Sulphur.-Menses too early, too profuse and of too short
duration; during menses, headache, rush of blood to head, nose-
bleed; burning in the vagina with troublesome itching of the genitals
due to papillary eruption.
Trillium.-Hemorrhage from the uterus with sensation as
though the hips and back were being pulled to pieces; better
from a tight bandage. (Cowperthwaite.) Hematuria; profuse
nosebleed; bleeding from gums; hematemesis.
(v. Therapeutics of dysmenorrhea, amenorrhea and uterine
hemorrhage).
Illustrative Cases.
CASE XLV. Dropsy and Hematuria Attending Pregnancy.-In this case preg-
nancy was attended by dropsy and hematuria. A young woman four to five months
pregnant for the first time, came to the London Hospital, having had dropsy for some
weeks; it was general; the labia majora were much distended. There was hydremia
and she complained of palpitation. She passed blood in the urine.-Barnes.
CASE XLVI.-Vicarious Hemorrhages from Stomach, Eyes and Nose.-M. A., æt.
30, single. A stout, strong woman, admitted complaining of distressing soreness of the
stomach and pain in the left shoulder, extending down the arm, which was rigidly
flexed; the least attempt to move it caused great pain. After being ill a month she
vomited a large quantity of blood. She was carried to bed fainting-vomiting of
blood recurred every month. The menstrual discharge which occurred at the same
time, was regular both as to time and quantity. She afterwards bled from the eyes
and from the nose. She had copious lachrymation, and a serous discharge from the
ear and profuse perspiration. Everything bespoke aggravated hysteria.-Law.
CASE XLVII.—Vicarious Hemorrhage from Strumous Scars, Eyes, Knees, Thighs,
Chest, from the site of neuralgic pains and from the Stomach.-Madame X. had stru-
mous ulcers when seven months old, on the fingers of the right hand. These cicatrized.
At six years old she was seized with convulsive attacks two or three times a month;
and later a sanguineous exudation took place from the scars of the hand. One day,
under the influence of violent grief, blood came with the tears. From this time on
the hematidrosis broke out indifferently on the knees, thighs, chest, and grooves of the
lower eyelids. The menses appeared at eleven, when temporary improvement occurred,
but soon disturbances returned. Then bleedings nearly always followed a moral
emotion and complicated a nervous attack with complete loss of movement and sen-
sibility. At fifteen the nervous attacks became more violent. They disappeared during
her first pregnancy, and broke out again a year later, on the occasion of metrorrhagia.
Some time after this I saw her for violent nervous attacks. Again, the menses
being a few days in arrear, pains set in in the groins, thighs, breasts, head, hypochon-
dria and epigastrium; relieved by chloroform; then three attacks of epilepsy came;
then blood oozed from a patch on the scalp; next, all the neuralgic paroxysms were
accompanied by blood-sweating at the seat of pain. At intervals blood escaped from
the skin of the forehead; in the subpalpebral folds blood ran in drops.
The ap-
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pearance of the catamenia next day brought relief. I examined the exudation mi-
croscopically. It consisted of the elements of true blood. Similar attacks supervening an
arrest of menstruation recurred. Frequently she vomited blood. Relief followed
the appearance of menstruation.-Parrot, quoted by Barnes.
CASE XLVIII.-Vicarious Hemorrhage from the Leg, at the site of which an ulcer
formed, which bled periodically every month.—Mrs. G., æt. 41. When about fifteen
became subject to occasional sudden flushings of face, with slight confusion of ideas ;
healthy. She was bled for "fullness of blood." This went on for three successive
springs, when menstruation came on, and continued regularly until nearly six years ago.
Menses always scanty and short. The flushings disappeared after the occurrence of
menstruation. Six years later, after considerable exertion in breaking sticks, which
she did with her right foot, she felt a pain in the calf. The skin became inflamed,
and an ulcer formed over the outer and lower aspect of the leg. This ulcer never
healed. When admitted, it was about eight inches long by six inches broad; the tissues
around were slightly sunken; veins not varicose. The day after admission pretty
copious hemorrhage occurred from the ulcer. This continued forty-eight hours, in
spite of pressure by bandage. Fearing that this bleeding might have been caused by
some injury during her journey to the hospital, I enquired about it; the patient in-
formed me that since the date of the injury six years ago she had not menstruated at
all; but that every month, about the time of the expected appearance, the ulcer bled
for two days, that is, for the same time that the menstrual flow lasted, before its sup-
pression.
After the bleeding ceased the ulcer had the appearance of a callous, rather foul
ulcer.-Buchanan.
CASE XLIX. Vicarious Leucorrhea.-A girl aged twenty, sought relief for
chlorosis. Since fourteen she has complained of languor, pain in the back, distention
and pain in the abdomen, and mucous discharges from the vagina. For six years
copious leucorrhea took place every month, following upon aggravation of pain in
the loins, distention of the abdomen and lassitude.- Whitehead.
CASE L.-Vicarious Hemorrhage from the Lower Lip.-A. P., sixteen years of
age, had been an inmate of the Indiana Reformatory for Women and Girls, for some
months, before requiring my professional attention. On March 10, 1876, I found her in
the hospital room suffering with slight hemoptysis. To my surprise, I observed both
lips to be swollen, and of a purplish hue, the swelling and the dark color being much
more marked in the lower than in the upper lip-indeed, this was so dark and so
much enlarged, that for the moment I thought a gangrenous inflammation was im-
pending.
Upon closer examination I found a little blood oozing from the inner surface of the
lower lip.
In four days all hemorrhage had ceased, and the lips resumed their normal size
and color.
The patient's history was briefly this: Born of healthy parents, but a cast-away,
she had hitherto led a life most unfavorable for a healthy physical, intellectual, or
moral development. She menstruated at fourteen, and the function was normal for
two years, or up to the time of her admission to the Reformatory; it then ceased for
six months, when it reappeared in the abnormal form I have detailed. She was
VICARIOUS MENSTRUATION.
303
delicate in form and quite anemic. Iron was prescribed. A month after my first
prescribing for her, there was a return of precisely the same symptoms that I have
mentioned as observed on March 10th. May and June each repeated the previous
history. Soon after the third recurrence of the abnormal menstruation, she made her
escape from the Institution-an unfortunate escape for her own good, and for the in-
terests of professional study.—Parvin.
CASE LI.-Amenorrhea with Vicarious Hemorrhage. The patient is a young
mulatto woman, whiter than most white women. She was married several years ago
and gave birth to one child. Always been regular in her menstrual periods until
two years before coming to me. At that time another colored woman stole her
husband's affections from her and followed up the theft by attempting to cut her
throat. She lost a good deal of blood from the wound. Her menses coming just at
this time, she said her physician gave her two kinds of bitter medicine to stop the
flow, saying she had lost blood enough. The "bitter medicine" proved effectual,
as she had but three catamenial periods in the two years following, at which time she
suffered with severe pains in the back and pelvis. About two weeks before I saw
her she felt the symptoms of the approaching menses, but instead of the usual flow
she bled profusely from both nipples. The mammæ were painful and tender to
touch before the hemorrhage. I found the uterus in a normal condition.
The patient complained of a throbbing in the temples at times. Also of
a dull headache, made worse by stooping, and attended with constipated bowels.
Belladonna and bryonia relieved her wholly of these ailments. I then prescribed
cimicifuga in a low potency. There was every indication of the natural appearance
of the menses at the next month, but at that time she went out in the rain and got
her feet wet, and no flow appeared. I continued the cimicifuga and the following
month she had a more natural and profuse flow than at any time since her troubles
began. Dr. S. J. Millsop, The Clinique, April 15, 1890.
CASE LII.- Vicarious Hemorrhage from Varicose Ulcers of the Legs.-Woman in bed
for large varicose ulcers of both legs. Heard some bad news. Menstruation, which was
going on, suddenly ceased, and ulcers began to exude blood, and continued to do so,
despite compression, for three or four days. Following month ulcers, though much
reduced in size, suddenly began to exude blood again, and menstruation did not appear.
Ulcers healed up before next period, and patient was discharged.—Bedford-Fen-
wick.
CASE LIII.-Singular Case of Vicarious Menstruation.-A negro woman, about
thirty-five years of age, of apparently good constitution, and, with the exception about
to be mentioned, of general good health.
She began menstruating at the age of fifteen, and continued regular in this re-
spect until three years since. Eight years ago, when about twenty-seven years of age,
she was attacked with a violent pain in the foot, which was succeeded by an abscess,
which was lanced, but did not heal. Ulceration succeeded, which continued to
move upward until the leg was involved and became the seat of its permanent loca-
tion. About three years since the catamenial discharge began manifestly to decline,
and so continued until it ceased altogether, when she was seized with severe shoot-
ing pains, passing from the sacro-lumbar to the uterine region, and to the ovaries.
At the approach of her next menstrual period she noticed a slow oozing of blood
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from the ulcer on the leg (I give her own account of the matter), which continued
about the usual time of that discharge and ceased. At subsequent periods the same
discharge sometimes occurred, while at others, small sacks of blood were formed
contiguous to the ulcer, which were obliged to be opened and the blood discharged
before relief could be obtained.
In June last, the ulceration of the leg had become so extensive and threatening, as
to require, in the judgment of Dr. -(whose patient she then was), amputation.
Since the operation, the ulcer being removed, there has been no regular monthly
periodic discharge of blood, but at each monthly period, sacks, such as were above de-
scribed, formed around the stump of the amputated limb, and required to be lanced
for the relief of the patient. I have seen these sacks, and in fact opened them, and
can entertain no doubt as to their true nature. So uniform are these singular oc-
currences in their periodic character, as to have induced this woman to keep a lancet
for the purpose, and thus surgically to perform the work of menstruation. It should
be observed that she continues without any vaginal discharge, and that the deter-
mination of blood to the stump of the amputated limb, together with the formation
of these sacks of blood, occur periodically, and observe strictly the menstrual periods
as to the time of their recurrence and duration.-Dr. Doring, New York Journal of
Medicine, Jan., 1856.
The following cases came under my own observation :—
CASE LIV.-Vicarious Hemorrhage from Hemorrhoidal Tumors of the Rectum.
-Mrs. B., æt. 36. Patient came to me from the northern part of the State, in July, 1886,
stating that her physician had made a diagnosis of "cancer of the rectum," without,
however, resorting to a local examination, although she had suffered intensely for three
years. She was pale and anemic, and for the last twelve months had lost enormous
quantities of blood from the rectum. Menstruation had been entirely suppressed for
five months, and rectal hemorrhage, although recurring in small quantities after each
stool, presented all the elements of periodicity. A series of rigid cross-questions were
put to the patient, in order either to confirm or disprove her statement; the statement
was incontrovertible. An examination revealed, not a carcinoma, but a mass of
hemorrhoidal tumors which were greatly aggravated by opium, the patient taking the
tincture in tablespoonful doses. On August 30th I ligated and removed the hem-
orrhoids. I gradually withdrew the opium, prescribed nux vomica, and the patient
made a good recovery. Two weeks after the operation she menstruated in a natural
way, the first time in five months. She also menstruated Sept. 20th and Oct. 25th,
since which time I have lost sight of the case.
CASE LV.—Vicarious Hemorrhage from a Mole on the Forehead.—E. B., æt. 20.
Of Irish descent, nervous temperament, but not hysterical, and a victim of spasmodic
dysmenorrhea. This patient was not under my observation long enough to permit
a careful study of all the symptoms. She caught cold just as the menses were due,
and, as a consequence, was suffering much more than usual from dysmenorrhea.
Upon reaching the bedside I found her bleeding quite profusely from a small mole,
not larger than a millet-seed, located on the forehead. Several large handkerchiefs
were completely stained with the discharge, of which there was not less than an
The face was red, the headache intense, and the restlessness very great.
Under the use of hot cloths externally over the abdomen, and a hot foot-bath, with
ounce.
VICARIOUS MENSTRUATION.
305
aconite internally, the natural flow was established, when the vicarious discharge
ceased. She gave a history of being similarly affected a year or so before, and has
had a recurrence of the ectopic discharge two or three times during the last eight
years.
CASE LVI.- Vicarious Epistaxis.—O. A., æt. 13. She is large for her years, well
developed, the mammæ being prominent, with quite a heavy growth of hair upon the
pubes. Every four weeks, for the last six months, she has had a profuse epistaxis.
The attacks recur every twenty-eight or thirty days. Pulsatilla was prescribed, and
in due time she became quite regular, when the epistaxis ceased. During the six
months while suffering from the epistaxis she did not menstruate.
20
CHAPTER XXI.
STERILITY AND IMPOTENCE.
Sterility is a symptom, or, rather, the consequence, of so many
different conditions and affections as to make it unnecessary in
a chapter devoted especially to the subject to do little more than
classify the causes, and to suggest the general principles of
treatment.
To make human fecundation possible, it is necessary—
1. For living spermatozoa to find their way into the female
genital tract;
2. For the contact of spermatozoa or a spermatozoön in some
portion of the genital tract with a healthy ovule capable of fertil-
ization; and, finally,
3. For the occurrence of suitable changes within the uterus,
that the impregnated ovule may not be prematurely expelled.
The statistics of Matthews Duncan* show that about one mar-
riage in every ten is fruitless. The various factors responsible
for this may be classified as follows:
1. Causes preventing insemination—
Impotence of the male;
Impotence of the female;
Stenosis of the vagina or ostium vaginæ.
2. Causes preventing or interfering with coitus—
Atresia or stenosis of the vagina;
Imperforate hymen ;
Malformation of the external genital organs;
Hypertrophy of the clitoris and labia;
Vaginismus ;
Prolapse of the ovary;
Undue shortness of the vagina;
Fissures and neuromata;
*"Gulstonian Lectures," 1883.
{
306
STERILITY AND IMPOTENCE.
307
3
Uterine and peri-uterine inflammation;
Hypertrophic elongation of the cervix;
Coccygodynia ;
Disproportion between the size of the male and female
organs.
3. Causes preventing passage of semen from vagina into uterus—
Inflammatory occlusion of the cervical canal;
Fibroid tumors and polypi;
Uterine displacements;
Conical shape of cervix;
Lacerations of cervix.
4. Causes preventing passage of ovule into uterus—
Fallopian stenosis;
Fallopian adhesions;
Absence of tubes.
5. Causes interfering with ovulation—
Ovaritis and the various peri-uterine inflammatory dis-
eases;
Abnormal states of the blood interfering with the mat-
uration of ova;
Tuberculosis;
Syphilis ;
Gonorrhea.
6. Causes interfering with gestation-
Endometritis ;
Subinvolution and aerolar hyperplasia ;
Tumors of the uterus;
Membranous dysmenorrhea;
Uterine hemorrhages.
7. Causes destroying vitality of semen-
Abnormal vaginal secretion;
Abnormal uterine secretion;
Syphilis ;
Tuberculosis.
!
It will be seen by this long array of causes that sterility may
be permanent or temporary, congenital or acquired, absolute or
relative.
308
A TEXT-BOOK OF GYNECOLOGY.
I. Causes Preventing Insemination.-The first fact to be
determined when called upon to treat a case of sterility is the
procreating power of the male. It is certainly most unjust to
subject the wife to an examination and a long course of treat-
ment, only to discover at the end of some weeks or months that
the fault lies not with her, but with the husband.*
By the term impotence is meant the inability to perform the
sexual act. In the male, this may be due to a number of causes,
either temporary or permanent. It not infrequently results from
excesses and early indiscretions, but oftener from some exhaust-
ing disease which has greatly depressed the system. Temporary
impotence is not uncommon in the newly married, especially
with men who are victims of the horde of unscrupulous quacks
that infest the land. They have had impressed upon them the
probabilities of impotence, and enter into marital relations with
fear and trembling. The mind plays no insignificant part in
the sexual act, and if the first attempt is not successful, as it
frequently is not, an impotence more or less permanent is de-
veloped which is purely mental. Dr. Hammond† has placed on
record several cases of this nature.
To all appearances the sexual act may be completed in
a most natural way, yet no semen is ejected; or, the semen
ejected may not contain healthy spermatozoa, hence the sterility.
In order to determine the presence or absence of spermatozoa,
an examination should be made soon after it is ejected by plac-
ing a drop of the fluid under the lens of a good microscope.
The spermatozoa consist of a large number of ciliated cells held
in suspension by the thick, watery portion of the semen. These
cells, if normal, should be seen to move about in every direction
under the field of the microscope.
Impotence in the female may be due to absence of sexual de-
sire, to physical conditions preventing the entrance of the male
* De Sinety estimates that in unproductive marriages the husbands are at fault in
fifty per cent. of all cases. Treu's (La Semaine Médicale, Aug., 1889) estimate is
thirty-six per cent. Fuerbringer (Deutsche Medicinische Wochenschrift, 1888) like-
wise believes that barrenness is due to some defect in the virile powers of the male
oftener than is supposed.
+ "Sexual Impotence in the Male and Female,” 1887.
STERILITY AND IMPOTENCE.
309
organ into the vagina, or to inability to experience the sexual
orgasm. A few words only in regard to the first and last of these
causes. Frigidity on the part of the woman may be the cause
of impotence in the male. That is to say, a man may not, be-
cause of lack of proper response or encouragement, have his
virile powers sufficiently stimulated to complete the act. In-
stances of this kind are, however, rare, though the sexual
appetite is very much below the normal in many women. The
causes for this have been classified by Hammond as follows:*
Absence, or arrest of development of the clitoris ;
Extreme smallness of the clitoris ;
Original absence of sexual desire.
I think there is no question that in the majority of women the
sexual orgasm is largely centered in the clitoris. This is not,
however, true in all cases, for in many the seat of sexual pleasure
lies either in the vagina, the vulva, the uterus, or equally in all
of these organs.
In
Some women do not seem to realize they have a clitoris.
instances of the kind proper instruction regarding the function
of this organ during the sexual act will put matters right and
the orgasm will be experienced. I have more than once found
the clitoris, in women devoid of sexual desire, bound down by
adhesions; after liberating the glans, sexual intercourse was
perfectly normal.
It is easy enough to comprehend that these various anatomical
defects may give rise to impotence. There yet remains a goodly
number of women in whom no such defects and, indeed, no
abnormal condition of any kind can be found. Sexual inter
course is not painful; the patient may possess most affectionate
qualities; the act itself is not repugnant, yet she experiences not
the slightest degree of pleasure, even though she makes every
effort to do so. There is, in the language of Hammond, “an
original absence of sexual desire." It is probable that this
inherent absence is of rare occurrence. Usually there exists
some reason for it—a reason which keeps a latent desire from
asserting itself. Too often it is incompatibility between husband
* Op. cit., p. 278.
310
A TEXT-BOOK OF GYNECOLOGY.
and wife. At any rate, I have known women absolutely devoid
of sexual desire while living with their first husband to possess
it to a marked degree after a second marriage. This incompa-
tibility is, when it exists, always a source of unhappiness, and
has not, I feel confident, received from the medical profession
the attention it deserves.
The sexual appetite may be absent for some time after mar-
riage, but gradually develops as time goes on-perhaps after the
birth of one or more children. I have had related to me many
instances of this kind.
While it is probable that a frigid woman is not so apt to con-
ceive as one possessing a normal or exaggerated sexual appetite,
yet many women thus affected are very prolific. Of course,
if the frigidity is such as to fail to excite the virile powers of the
male, then, indeed, it may absolutely prevent, indirectly, insemi-
nation. Fortunately, such instances are very rare-much more
so than are instances of large families coming to women who
have never experienced the sexual orgasm.
Is intromission necessary for fruitful insemination ? I think
that this question can be positively answered in the negative.
The self-propelling power possessed by the spermatozoa enables
them, even when deposited upon the external organs, to find
their way upward through the vagina and into the uterus. Tes-
timony bearing upon this point is sometimes necessary in cases
of alleged rape.
2. Causes Preventing or Interfering with Coitus.-These
several causes require no great amplification. Some of them
interfere or prevent coition because of mechanical obstacles inter-
posed to the entrance of the penis into the vagina; others make
sexual intercourse impossible because of the pain resulting from
an attempt to perform the act.* These several pathological con-
ditions have elsewhere received due attention.
It should not be forgotten that failure to consummate the
act may be due to simple awkwardness on the part of the male, or
to want of proper gentleness. The vagina is sometimes unnatur-
ally small, or the male organ unusually large. This disparity in
either event interferes with coition or makes it impossible.
* " Dyspareunia.”
STERILITY AND IMPOTENCE.
311
3. Causes Preventing the Passage of Semen from the
Vagina into the Uterus.-Occlusions of the cervical canal
occasionally result from sloughing or from inflammation follow-
ing intra-uterine applications. A local examination will be
necessary in order to determine this condition. Fibroid tumors
and polypi impinging upon the cervical canal act as an obstacle
to the passage of the spermatozoa. Even a very small polypus
may cause sterility.
Uterine displacements are likewise a frequent cause of sterility.
In the case of flexures the uterine axis is so changed that the
organ is bent upon itself in the form of a retort. Deformities
of the cervix from any cause may prevent the entrance of the
semen into the uterus. The so-called conical cervix may make
it difficult for conception to occur. Lacerations of the cervix,
notwithstanding the increased size of the cervical canal, are fre-
quently associated with sterility. I have known many instances
where women have not conceived for years, but have become
pregnant soon after the cervix was repaired. The probable
reason for this is that a lacerated cervix perpetuates endometri-
tis, the discharge from which obstructs the cervical canal.
4. Causes Preventing Passage of the Ovule into the
Uterus.-The Fallopian tubes are often obstructed by preëxist-
ing disease. Indeed, it is surprising that pelvic inflammation
in its severer forms ever runs its course without permanently
occluding the tubes. They are frequently involved in inflamma-
tion, but, unless bound down by adhesions, usually regain their
normal function. If, however, the adhesions are extensive, or
if pus forms in the tubes, it is next to impossible for the ovule to
pass through them into the uterus. There is nothing in the
physiology of menstruation more remarkable than the manner
in which the ovule finds its way into the Fallopian tubes, even
in normal conditions. It is probable, as suggested by Tait, that
in the majority of instances, the ovule instead of finding its way
into the Fallopian tubes drops into the free peritoneal cavity.
If this be true, even though the parts be normal, it is certainly
much more apt to be the case if there exist disease of any kind.
In the vast majority of cases women with peri-uterine inflamma-
tion are sterile because of the distortion and disease either of the
312
A TEXT-BOOK OF GYNECOLOGY.
tubes or the ovaries. In rare instances the tubes may be con-
genitally absent.
5. Causes Interfering with Ovulation.-The same diseases.
involving the tubes frequently involve the ovaries as well.
Ovulation will, however, sometimes continue in spite of most
extensive disease. I have dug ovaries from inflammatory
exudates containing Graafian follicles ready to burst, or Graafian
follicles which have just ruptured. I have also removed.
ovaries showing evidences of recent ovulation whose structure
was almost completely degenerated. It is well known that
conception may take place in women suffering from chronic
inflammation of one ovary, though sterility is the usual result
when both ovaries are implicated. Nevertheless, we must not
too quickly sacrifice ovaries chronically inflamed. The
reason why it is exceedingly hard to cure the disease is that
perfect physiological rest, so long as the patient men-
struates, is impossible. The nearest approach will be a cessa-
tion of ovulation, the result of pregnancy, and pregnancy will
sometimes follow in the most unfavorable cases.
There are certain abnormal states of the blood which interfere
with the maturation of the ova. Anemia, chlorosis, syphilis,
tuberculosis, or any condition seriously interfering with the
blood-making processes may so depress the system as to affect
the function of ovulation. Gonorrhea is often responsible for
sterility. I have in another place (Chapter XXVI) dwelt in detail
upon this subject. The frequent involvement of the ovaries
and tubes in patients suffering from gonorrhea is no longer
questioned. While gonorrheal inflammation of the ovaries may
not be more virulent than non-specific inflammation, yet I
believe that the specific form of vaginitis is much more apt to
extend to the tubes and ovaries than is the non-specific.
6. Causes Interfering with Gestation.-The list of causes
includes those conditions which are inimical to the life of the
ovule after it reaches the uterus. Indeed, many of the
causes there enumerated are fatal to the life of the spermatozoa
before they reach the ovule. Thus, endometritis, because of the
abnormal secretion, interferes with the growth of the ovule.
So do subinvolution and areolar hyperplasia, though there is
STERILITY AND IMPOTENCE.
313
usually associated with these affections more or less endome-
tritis. Tumors of the uterus either prevent that organ from
growing or impinge upon the intra-uterine cavity in such a way
as to cause premature expulsion of the ovum. Victims of
membranous dysmenorrhea are nearly always sterile. This
peculiar affection makes it almost impossible for the uterine
mucous membrane to undergo those changes which are neces-
sary for the reception of the impregnated ovule. Women
suffering from menorrhagia and metrorrhagia are often sterile,
not so much because of the excessive discharge, as because of
the lesion or lesions which are responsible for the hemorrhage.
7. Causes Destroying the Vitality of the Semen.-Ex-
cessive acidity of the vaginal secretion will destroy the life of
spermatozoa. Cases in which this unnatural condition exists
are not uncommon. Sometimes the acidity is so great as to
make the discharge most excoriating. It may even excite
intense irritation of the male organ after intercourse. I have
more than once been able to detect this unnatural condition in
making a digital examination, the finger smarting when coming
in contact with the discharge. Abnormal secretion of the
uterus has already been referred to. It may be due to numerous
causes. While usually not acid in its reaction, yet if its pro-
perties are markedly changed it will destroy the vitality of the
semen.
The part played by obesity in the production of sterility
deserves some attention. Philbert * has recorded five instances
of sterility in women unnaturally obese, all of whom became
pregnant after the reduction of flesh. It is probable, as sug-
gested by Fournel,† that the disease of the blood corpuscles
which results in obesity affects also the uterus and ovaries, thus
interfering both with the function of ovulation and the nutri-
tion of the uterus. Obese women usually suffer from relaxation
of the muscular fibers throughout the body, and the tissues of
the uterus may likewise become implicated. At any rate, when
conception does occur in cases of the kind, labor is usually
* Revue Générale de Clinique et de Therapeutique, April, 1889.
† Gazette des Hôpitaux, February, 1889.
314
A TEXT-BOOK OF GYNECOLOGY.
most tedious. Obese women are also victims of miscarriages
oftener than those of normal flesh. This is due, according to
Fournel, to asphyxia of the fetus because of deficient oxidation
of the blood corpuscles, the resulting accumulation of carbonic
acid exciting uterine contraction and thus expelling the fetus.
Duncan * states that "the average time after marriage for the
birth of the first child is about one year, though not infre-
quently three years elapse before the birth of the first child, and
we are hardly justified in assuming that permanent stérility
exists until after this time." He also considers the average
interval between the birth of successive children at from eigh-
teen to twenty months. And he affirms that the physiological
number of children for each fertile woman closely approaches
ten. Too much stress must not, however, be placed upon these
deductions. Causes of various kinds, especially social, may and
frequently do disturb these averages.
Syphilis, tuberculosis, scrofulosis, etc., of the male are not
infrequently responsible for sterility. I have already referred to
the necessity of examining the semen where there is a possibil-
ity of the male instead of the female being at fault.
Treatment. Some of the causes of sterility which I have
presented are remediable, though many are not. Most of the
stenoses can be overcome by proper operative treatment.
The removal of imperforate hymen is neither difficult nor danger-
ous. The possibility of curing malformations of the external
genital organs will depend entirely upon their nature. Hyper-
trophy of the clitoris and labia is to be reduced by the scalpel.
Vaginismus-often a most obstinate condition to contend with-
can usually be overcome in time by combined internal and local
treatment. Nothing more fortunate can befall a patient suffering
from vaginismus than pregnancy, for the affection frequently dis-
appears after the birth of the first child. Prolapse of the ovary
is also a most obstinate affection; too often the resulting distress
can only be overcome by abdominal section and removal of the
displaced organ, or by attaching the fundus uteri to the anterior
abdominal wall. There is no way of lengthening a short vagina;
* Op. cit.
STERILITY AND IMPOTENCE.
315
it is possible, however, for conception to occur even here. The
patient should be instructed to lie with her hips elevated for
some time after intercourse, so that the semen may be retained.
Fissures and neuromata are barriers easily overcome, though
they usually require surgical interference. The prognosis in
uterine and peri-uterine inflammation will depend largely upon
the extent of involvement of the Fallopian tubes and ovaries.
Irreparable damage may be done to both, or it may be possible
to restore them to their normal condition. Hypertrophic
elongation of the cervix must be reduced by the scalpel.
In occlusions of the cervical canal from whatever cause
divulsion is to be practised.* In a goodly number of cases of
uterine flexures, when the patient is otherwise healthy, concep-
tion will follow this operation.† In the event of fibroid tumors
or polypi the prognosis will, of course, depend upon the pos-
sibility of removing the adventitious growths.
Where causes exist preventing the passage of the ovule into
the uterus, the prognosis is more unfavorable. It is exceedingly
difficult to overcome Fallopian stenosis when the obstruction is
due to inflammatory adhesions. Even here, however, measures
having for their object the absorption of adhesions and the
removal of inflammatory exudates may overcome the obstruc-
tion. The pain resulting from extensive adhesions which
involve the ovaries is, unfortunately, so great in most instances
as to require salpingo-oophorectomy. Absence of the tubes
is by no means an easy matter to determine. Once deter-
mined, it is hardly necessary to state that further effort is
useless.
In the event of serious systemic disturbance much good may
be accomplished by proper hygienic, dietetic, and general treat-
* Outerbridge has devised an instrument, consisting of a continuous steel wire
made so as to form two blades, which he introduces into the cervix six days in advance
of the menstrual flow, allowing it to remain in position for from five to eight days
after the period. He reports several successful cases following the introduction of this
instrument. If it is used at all, I should recommend the same precaution to be observed
as in the use of the intrauterine stem, keeping the patient in bed until after its
removal.
† v. page 269.
316
A TEXT-BOOK OF GYNECOLOGY.
1
ment. It is not an uncommon thing for women whose nutrition
is seriously interfered with from any cause to conceive after
being restored to a state of health. As regards tuberculosis, if
this is responsible for the sterility, it is indeed most fortunate
that the patient is sterile. It would, in my mind, be a most cruel
thing to encourage a victim of tuberculosis to bear children, or
to resort to any operation which would make conception more
probable.
When the blood taint is due to syphilis, anti-syphilitic treat-
ment will sometimes make a sterile woman fruitful; or, if the
husband is the infected party, the same treatment directed to
him will often restore his virile powers. Sometimes a lacerated
perineum will prevent the retention of semen within the vagina
for a sufficient length of time to enable it to pass into the cervi-
cal canal. The indications here are clearly to restore the peri-
neum by a proper operation.
So far as internal medication is concerned, it is useful just in
proportion as it is useful in the several affections which have
been considered as causative factors. As has been shown,
sterility is a symptom of innumerable causes and diseases, and
it seems to me the height of folly to prescribe for it as an affec-
tion per se.
I therefore deem it unnecessary to give a list of
indicated remedies.
In conclusion, I desire to take issue with certain recent writers,
notably Reeves Jackson and Professor John Thorburn, in the
statement that no operation should be performed solely for the
purpose of overcoming sterility. These gentlemen infer that the
desire for offspring on the part of husband or wife does not in
itself warrant interference, or, at least, operative interference in
any way endangering the life of the patient. They maintain
that, if surgical measures are necessary for the removal of causes
which in themselves demand surgical measures for the relief
of the existing symptoms other than sterility, the physician
is justified in operating; otherwise he is not. This would ex-
clude from operative treatment that class of patients in whom
nothing abnormal can be found by the ordinary methods of
examination. Dysmenorrhea may even be absent, and yet
divulsion of the uterine canal will sometimes be followed by
STERILITY AND IMPOTENCE.
317
conception. This, under proper antiseptic precautions, is but
slightly dangerous. I maintain that when a woman desires to
assume the responsibilities of maternity every resource which
does not too greatly endanger life or shock the sensibilities
should be exhausted. At this day and age there are too many
women shirking this responsibility, and the future happiness of
both the husband and wife may, in no small degree, depend
upon the advent of a babe into the household.
The results of artificial impregnation have not been sufficiently
satisfactory to warrant a description of its technique. It is to
me a most revolting procedure; and it is a serious question
whether or not, in the alleged successful instances where it has
been practised, impregnation was not due to the dilatation inci-
dent to the introduction of the syringe into the cervical canal
rather than to the transmission of semen through the syringe. At
any rate the percentage of successes following this procedure is
so low that doubt is raised as to whether, in the instances in
which pregnancy has resulted, conception would not have
occurred without it.
DYSPAREUNIA.
This term, reintroduced by the older Barnes, is applied to that
condition in which sexual intercourse is, in the female, attended
with pain. It is a symptom of many of the affections enumerated
as causes of sterility and of the various local diseases of the
external and internal genital organs which are elsewhere dealt
with.
Painful sexual intercourse in women is not of uncommon
Occurrence. When it exists to any marked degree its impor-
tance cannot be overestimated, for the consequences are some-
times most disastrous. If the attempt be persisted in, the result-
ing distress will undermine the patient's health and may give
rise to serious mental or nervous disease; if, on the other hand,
no further effort be made to consummate the act, marital infe-
licity may ensue. The subject is always a delicate one, and
many times suffering is endured for years before the physician
is consulted. I have more than once found dyspareunia at the
bottom of some seemingly obscure nervous affection, the cause
not being disclosed to me until after the patient had been under
318
A TEXT-BOOK OF GYNECOLOGY.
treatment for some time. Women of nervous organization are
often completely upset by even a slight degree of pain during
the sexual act. When it is at all marked the sexual orgasm is
not experienced, and, under these circumstances, ungratified
sexual excitement is injurious.
When a lesion easily detected exists, there will be little diffi-
culty in finding the cause of the dyspareunia. Often, however,
the seat of the mischief is more obscure, and to locate it requires
no little tact.
The trouble may be purely mental. Too often the girl is per-
mitted to assume marital responsibilities while perfectly ignorant
of them. She is not only surprised but shocked on discovering
the rôle she is to play. If the husband is likewise ignorant, or if
his ideas of the sexual relations have been obtained from impure
sources, the first attempts at intercourse, because of awkwardness
or lack of gentleness, are exceedingly painful to the female.
Subsequent efforts are made with fear and dread, and in due time
a peculiar nervous state is engendered in which even the thought
of intercourse will result in spasm of the muscles of the pelvic
floor (v. Vaginismus). The time is fast approaching when all
educated mothers will realize that their full duty will not have
been done until their grown-up daughters have received from
them some knowledge bearing upon sexual hygiene and the
sexual relations.
Stenosis of the vagina, imperforate hymen, the various inflam-
matory diseases of the vulva, vagina, and the pelvic organs,
uterine and ovarian displacements-any or all of these several
affections may not only give rise to painful sexual intercourse,
but may make the act impossible.
Fissures and abrasions of the vulvar outlet, so insignifi-
cant at times as to make them difficult to detect, may be respon-
sible for the pain. These lesions usually follow a successful
attempt at intercourse. By exposing the parts to a good light
slight rents or abrasions of the mucous membrane will be seen.
If not extensive, they can ordinarily be healed by the patient liv-
ing for a time absque marito and applying to the parts lint soaked
in calendula and smeared with iodoform; or sprinkling the dis-
eased surface with iodoform and then painting it over with
STERILITY AND IMPOTENCE.
319
oleaginous collodion. The collodion acts as a protective and is
most useful. In the case of fissure, if this treatment fails, an in-
cision should be made through it, as in dealing with fissure of
the rectum.
A prolapsed ovary is nearly always tender, and when the penis
comes in contact with it the distress is usually very great. An
examination, per rectum or vaginam, will determine the cause
of the dyspareunia. But a prolapsed ovary may give rise to
pain and spasm at the ostium vaginæ in a purely reflex way; it
is important to bear this fact in mind when looking for the cause
of vaginismus when no visible lesion is found to explain the
hyperesthesia of the vaginal outlet.
Neuromata and carunculæ, located at the hymeneal base or the
urethral orifice, are often exquisitely sensitive. In size they
vary from a pin head to a hazel-nut. The smaller ones may be.
difficult to detect. In order to cure these growths thorough
eradication is necessary.
The cause is occasionally located some distance from the
vagina and genital tract. Rectal lesions, fissures, hemorrhoids,
etc., may give rise to dyspareunia. Coccygodynia is another
cause which will remain undetermined if the examination is
confined to the genital organs.
When a woman presents herself suffering from this distress-
ing symptom, every effort should be made to determine and
remove the lesion responsible for the difficulty. Intercourse
should be forbidden while the patient is undergoing treatment,
and it is usually wise to separate her temporarily from her hus-
band. A little judicious advice given to the husband will often
result in much good.
CHAPTER XXII.
DISEASES OF THE EXTERNAL ORGANS
OF GENERATION.
General Considerations.-The importance of certain dis-
eases affecting the external organs of generation is greater than
is imagined. I refer especially to that class of affections which,
though exceedingly distressing and painful, give rise to but
little deformity. Of course those diseases which result in
deformity, like cancer, tumors, elephantiasis, etc., compel atten-
tion. The lesser affections, on the other hand, frequently give
rise to the most excruciating suffering, and because the patient
cannot detect the actual evidences of disease, or perhaps
because of the consciousness that an ocular inspection on the
part of the physician will be necessary, she suffers indefinitely
before seeking medical aid. It is impossible to exaggerate the
evil consequences of a long-continued pruritus vulvæ, a
frequent symptom of the various affections to be dealt with in
this chapter, especially in a girl or woman with a highly wrought
nervous system. Sexual excitement results in many instances,
and onanism in the female has, I believe, its usual origin in some
pathological lesion of the vulva setting up irritation and itching.
Then, too, there is a peculiar tendency to chronicity with many of
these diseases. In spite of the most carefully selected internal
remedy and the most energetic external applications, they
often run a protracted course. This obstinacy is due in many
instances to the long-continued duration of the symptoms before
the physician is consulted, for, owing to the reasons already
given, the average woman shrinks from the necessary examina-
tion, which is infinitely more embarrassing to her than is simple
digital or specular exploration.
Unless there is a marked degree of deformity, or unless the
patient is able accurately to locate the diseased area, the dorsal
320
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 321
position is necessary for a satisfactory examination. By sepa-
rating the labia with the fingers of the left hand, and by the aid
of good side or reflected light, the disease, whatever its nature,
can usually be detected. A more careful exploration is, how-
ever, sometimes required in order to discover minutely hyperes-
thetic points, and for this purpose a delicate silver probe, supple-
mented by a good magnifying glass, should be used.
DEFORMITIES OF THE VULVA.
Under this head are included hypertrophy and atrophy of the
labia majora and of the nymphe, and hypertrophy and atrophy of
the clitoris. Deformities resulting from injuries to the perineum
are treated of in the chapter devoted to that subject.
Hypertrophy of the Labia Majora and of the Nymphæ may
result from hyperplasia following inflammation, from mastur-
bation, elephantiasis or syphilis. When limited to the labia majora
it may be great enough to cause them to reach the anus, hang-
ing in folds. The increase in size is rarely so great as this,
though the slighter and more moderate degrees of hypertrophy
are of frequent occurrence. Hypertrophy of the nymphæ is
oftener observed, and not infrequently they hang below the labia
majora. It is more prevalent among certain races, and is
described by the older authors as the "Hottentot apron," be-
cause of its supposed greater frequency in that people. There
is often a lack of symmetry of the two sides. (v. Fig. 62.)
Winckel records two cases, in one of which the nymphæ
measured 4.6 inches and in the other 3.7 inches in length.*
The same author maintains that nineteen per cent. of pregnant
women have one of the nymphæ more developed than the
other.†
Atrophy of the Labia Majora and of the Nymphæ may be
*" Diseases of Women," p. 31.
+"Hypertrophied nymphæ may cause great inconvenience; it is, therefore, interest-
ing to note that H. Carrard has very recently been able to show that the cause is an
increase of their nerve-fibers, in the form of Meissner's tactile bodies, also in the
form of club-shaped terminations and peculiar tactile bodies having an aggregation of
adenoid tissue."- Winckel.
·
21

322
A TEXT-BOOK OF GYNECOLOGY.
either physiological or pathological. Senile atrophy of the
organs takes place after the climacteric and as old age approaches,
concomitantly with similar changes of the internal organs. Im-
perfect development or congenital absence may characterize the
external as well as the internal organs.
FIG: 61.
According to Hyrtl the clitoris is physiologically larger in
the tropics than in colder countries.
It is probable that the same causes
giving rise to hypertrophy of the labia
and nymphæ will give rise, if con-
tinued, to hypertrophy of the clitoris,
though Winckel maintains that it
does not occur as a result of mastur-
bation. The size of the organ varies
greatly within normal limits in
different subjects-from a mere tuber-
cle in the anterior commissure to an
erectile, miniature penis. The degree
of hypertrophy is also very variable
when it occurs. Frequently the en-
largement is congenital, though as-
suming new proportions at and fol-
lowing puberty. Tait has recorded a
case in which the clitoris was as large
as an infantile penis.* Parent-Duch-
atelet found in examining 6000 prosti-
tutes, three cases of hypertrophy in
which the clitoris was the size of the
ordinary male organ. (Fig. 61.)
Atrophy of the Clitoris, other
than senile, results oftener from ad-
hesions of the organ than from any other cause. I am fully
satisfied that this is a condition calling for the most care-
ful attention. By referring to Fig. 1, the location of the clitoris
and the manner in which the nymphæ form a prepuce will be
seen. This prepuce may become adherent, attaching itself to,
HYPERTROPHY OF CLITORIS.
A lobulated tumor was formed,
apparently by enlargement of the
prepuce of the clitoris. (Museum
R. C. S. Photographed by the
Author.)
This
*" Diseases of Women and Abdominal Surgery."

DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 323
and binding down the entire clitoris, exactly as the foreskin
in the male becomes adhered to the glans penis in phimosis.
That the results are equally pernicious I am fully convinced.
The peripheral nervous apparatus of the female sexual organs
reaches its highest development in the clitoris, and, consequently,
the sexual erethism is inaugurated in at least the majority of
FIG. 62.
HYPERTROPHY OF EXTERNAL ORGANS OF GENERATION.
The two lateral portions are probably the labia, each of which is six inches in length
and two or three inches in width. (Museum R. C. S. Photographed by the Author.)
instances, by normal or abnormal excitation of this region. I
say in the majority of instances, because the chief center] of
sexual erethism occasionally resides in other portions of the
genital tract-the uterus, vagina, and, probably, in the ovaries.
Where adhesions exist the clitoris becomes almost obliterated
by the overlapping prepuce, which forms the apex of the vesti-
bule. Sometimes the head of the glans will slightly project,
324
A TEXT-BOOK OF GYNECOLOGY.
and underneath the superficial adhesions a small quantity of
hardened secretion is seen. This condition is in the larger per
cent. of cases congenital, and when the nervous system in young
girls is unnaturally perturbed, with evident irritation of the
external genitalia, it is my practice to examine carefully for
an adherent clitoris.
That this condition may become in later life a source either
of irritation or want of irritation, there can be no doubt. The
accumulated secretions excite an itching which not infrequently
ends in onanism; or in due time the unnatural condition of the
parts results in a permanent atrophy with diminished or entire
loss of sensation which, in the married state, makes a complete
sexual orgasm impossible. In either instance the remote effects
upon the mind, and the nervous system in general, are most
pernicious. It is always well, therefore, in performing any opera-
tion upon the female genital organs to examine the clitoris, and,
if necessary, liberate the adhesions before the patient is removed
from the table.
The treatment of the various conditions resulting in deformity
of the vulva is both medicinal and surgical. Palliative applica-
tions, when chafing or itching is prominent, are most soothing
and useful. Frequent bathing followed by washes of calendula,
lead-water, carbolic and boracic acid solutions will often bring
to the patient temporary relief. Any one of the several appli-
cations and remedies recommended for pruritus vulvæ may be
used when the itching is troublesome.
Hypertrophy of the labia majora and nymphæ rarely call for
surgical interference, though, if large enough to interfere with
coition or locomotion, the knife may be indicated. The same
statement holds good as regards hypertrophy of the clitoris.
Clitoridectomy, recommended by Baker Brown in 1866, is no
longer a justifiable operation for the relief simply of nymphomania
or masturbation.* When the organ becomes sufficiently hyper-
*“ This is a dark page in the history of our progress, and the operation (clitoridec-
tomy), has not yet been abandoned. A short time ago I examined a young girl whose
clitoris had been partially removed, and the cicatrix afterward cauterized, because the
irritation had returned. What was the result?
What was the result? The irritation is more severe than
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 325
trophied to cause serious deformity it should then be removed,
for the purpose of reducing its size. Experience has demonstrated
that it is hardly possible to break up vicious habits by clitori-
dectomy, even though the most radical measures are practised
for the purpose of destroying every vestige of the organ.
When the operation is done for excessive hypertrophy it is best
done by the galvano-cautery loop, or the Paquelin. Hemor-
rhage is in most instances controlled by these methods, but if
the parts seem unduly vascular deep transfixion pins and the
elastic ligature may be used, after which the knife instead of the
cautery can be safely applied. If the cautery is not used deep
sutures should be inserted and tied before the pins and ligature
are removed.
The detachment of an adherent clitoris is easily accomplished,
though, owing to the exquisite sensitiveness of the parts, an
anesthetic is usually necessary. I have several times, in adults,
done the operation after applying a 20 per cent. solution of
cocain, but even then a good deal of suffering is caused. With
children an anesthetic should always be used. With the patient
in the dorsal posture, the labia are separated by an assistant or
with the unengaged hand. The clitoris is then carefully dis-
sected out by the application of a blunt instrument (the point of
an ordinary director) care being taken not to lacerate the organ.
After it is thoroughly liberated, the parts should be washed in a
weak solution of bichlorid, smeared with carbolized vaselin,
and protected with iodoform gauze. Subsequent dressings twice
a day should be made, the parts being separated with gauze in
such a way as to prevent their readherence.
ERUPTIONS.
The most frequent forms of eruptions occurring about the
vulva are eczema, lichen, acne, and furuncles. The pathology of
Eczema does not differ materially from eczema attacking other
parts of the body. Loss of hair, with thickening of the skin
ever, and manifests itself even when the patient looks at naked figures in galleries, etc.
West has protested against the operation for masturbation, and at this time the majority
of gynecologists are firmly convinced that it is quite as useless in epilepsy, hysteria, or
masturbation."— Winckel.
326
A TEXT-BOOK OF GYNECOLOGY.
and mucous membrane, result in due time. The disease usually
begins on the outer surface of the labia majora, involving sooner
or later the vulvar mucous membrane and the skin of the thighs
and abdomen. Pruritus is the chief symptom, and is often most
distressing. The connection of eczema vulva with diabetes mel-
litus is of such frequent occurrence as to call for a careful exam-
ination of the urine, especially in elderly women, in all instances
where the eruption does not yield to ordinary treatment. The
irritating character of the urine is not the sole factor in exciting
the eruption, for eczema in other parts of the body is a well-
known complication of diabetes.
The constitutional and local treatment of this form of eruption
does not differ from that of eczema in other parts of the body.
It is, of course, essentially constitutional if diabetes is at the bot-
tom of the difficulty. Chronic eczema is always an obstinate
disease, and exacerbations are of frequent occurrence. Cleanli-
ness is a sine quâ non, and yet the parts must be washed with
the utmost gentleness, the soap used being of the blandest kind.
'Medicinal applications will do but little good until the super-
ficial crust is softened and removed. As a preparatory measure,
therefore, and for the purpose of softening the tissues, a flaxseed
poultice is most useful and soothing.
The number of applications recommended for eczema is legion,
and I will give but few, referring the reader to special works for a
more extended list. Applications of lime-water will often con-
trol the intense itching. Of the ointments the various prepara-
tions of zinc stand at the head. Thornburn* recommends the
following: Zinci oleat., 5j, ad vaselin alb., 3ij; dilute hydro-
cyanic acid (mv−x ad 3j); chloral (3ss-3j ad 3j glycerinæ); the
glycerole of acetate of lead (grs. x-xx ad 3j); the unguentum acid
chrysophanic (3ss ad 3j); the glyceroles of tar, boracic acid,
carbolic acid, and salicylic acid. The itching may be so intense
as to call for the more powerful applications (nitrate of silver,
3j ad 3j; strong carbolic acid; caustic potash, 5ss ad 3j; or even
the solid nitrate of silver).
As in all forms of skin disease, the internal remedy should be
* "A Practical Treatise on the Diseases of Women," page 39.
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 327
selected with much care. If a cure can be accomplished with-
out the aid of external measures, other than those used for the
purpose of cleanliness, so much the better. I am compelled to
confess, however, that in my own practice eczema vulvæ has
given me much trouble, and in the chronic form I have been
unable to dispense with outward medicaments.
Lichen is usually confined to the pubes. The papules vary
greatly as regards numbers, and present the characteristic
thickened and slightly indurated bases. The treatment consists
of the indicated internal remedy and the application of some
powder (starch and boracic acid), for the purpose of keeping the
cutaneous surface perfectly dry.
Furuncles sometimes occur in troublesome succession on or
about the vulva. They may possess at their onset all the char-
acteristics of simple acne, becoming inflammatory in due time.
When large enough to cause suffering they should be poulticed,
and opened as soon as suppuration is evident.
Prurigo, Elephantiasis, Erythema, Syphilides, and Ery-
sipelas are forms of eruptive disease attacking the vulva with
greater or less frequency. Their clinical manifestations do not,
however, differ essentially from those present when the several
affections are located in other parts of the body.
VULVITIS.
Four types of vulvitis may attack the vulva-simple, purulent,
follicular, and gangrenous.
Simple Vulvitis is the form most frequently met with, and
occurs oftener in blondes than brunettes; for some reason the
secretions of the former decompose more readily than the secre-
tions of brunettes. The inflammation may result from irritating
discharges, from pediculi, or from pruritus. The prominent sub-
jective symptom is itching, and the act of scratching greatly
intensifies the disease. Ocular inspection will reveal a red and
more or less eroded surface, sometimes involving the anus and
nates.
The treatment must be directed to the removal of the original
causes. If due to irritating discharges from the uterus or
vagina these should be looked after. A tampon saturated in a
328
A TEXT-BOOK OF GYNECOLOGY.
boroglycerid solution will catch the discharges and prevent
their coming in contact with the inflamed surfaces. This expe-
dient will not only give temporary relief, but will serve as a
means of diagnosis. If it is not expedient to treat the primary
cause—vaginitis, cervicitis, endometritis, etc.,—the parts may be
protected by smearing over them carbolized vaselin or sprink-
ling them with fuller's earth, or boracic acid and starch (3j-3j).
The urine should be examined for sugar. Pediculi are to be
destroyed with ungt. hydrargyri, or by a bichlorid solution
(grs. iij-3j). The solution of bichlorid is much cleaner and is
usually efficacious. After the cause is removed the symptoms
of inflammation usually subside. Applications of hydrastis or
calendula may be advantageously made, supplemented, if neces-
sary, by such internal remedies as sulphur, cantharis, graphites,
and sepia.
The causes of Purulent Vulvitis are: gonorrhea, immoderate
coitus, onanism, traumatism, and uncleanliness. Simple vulvitis
may become purulent if the cause continues operative long
enough. The symptoms are characteristic of localized inflam-
mation, attacking muco-cutaneous surfaces-slight constitutional
disturbances, with first dryness and redness of the parts, which
soon become bathed with a purulent discharge. The discharge
frequently excites excoriation and itching. The neighboring
organs are often implicated-urethritis, vaginitis and cystitis
becoming complications. It is said that the urethra is oftener
involved in specific vulvitis than in non-specific. However this
may be, the only absolute way of differentiating between the
two forms of inflammation is by the aid of the microscope. It
is probable that specific pus is the more infectious, but
urethritis in the male may follow contact with the non-specific
virus.
Treatment. The recumbent posture, cleanliness, frequent
ablutions and warm fomentations are all important. I know of
nothing more soothing than a stream of warm water thrown
against the parts by the aid of a douche can. Calendula (1-10)
is a most useful application. A dossil of lint saturated in a
calendula solution should separate the opposing surfaces of the
labia after the parts have been thoroughly cleaned. Other
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 329.
sedative lotions and applications are: glycer. boracis žij, liq.
morphiæ acet. 3j, aq. rosæ 3v (Edis); Camphor 3ss., spir. vin.
rect. q. s., bismuthi carbonat. 3ss., pulv. amyli Zij (Edis); liq.
plumbi. subacet. 3j, tinct. opii 3j, aq. Oj. After the sub-
sidence of the acute symptoms arsenium and mercurious cor.
are the remedies oftener indicated.
In Follicular Vulvitis the mucous and sebaceous glands are
involved, either separately or conjointly, to such an extent as to
warrant the designation given. The causes are the same as in
the purulent form, except that it occurs often as a complication
of early pregnancy. The subjective symptoms, too, are much
the same as those of purulent vulvitis, though the pruritus is
usually of greater intensity.
The physical signs depend upon the glands chiefly involved.
If the sebaceous, the surface of the labia, extending as far as
their junction anteriorly, will be studded with small rounded
papillæ; if the mucous, small, red, elevated spots are seen upon
the mucous membrane of the vulva, which are very vascular
and exceedingly tender. The secretion is of an offensive odor
and may be great enough to conceal the prominent follicles.
Follicular vulvitis runs an exceedingly obstinate course, and
the prognosis should be guarded. If it occurs as a complica-
tion of pregnancy it may continue throughout the entire period.
Abortions have resulted from the intensity of the pruritus.
Vaginismus sometimes occurs in the non-pregnant, because of
its protracted course. The virus is even more virulent than
that of purulent vulvitis.
The treatment does not differ essentially from that given in
uncomplicated purulent inflammation, except that it may have
to be more energetic. When the follicles are distended with
pus they should be freely opened and their bases destroyed and
washed with a weak bichlorid solution. This is to be followed
by a moist carbolized dressing (two per cent.) as recommended
by Thomas. When the course run is more chronic the inflamed
points may be treated with a nitrate of silver stick or impure
carbolic acid.
Gangrenous Vulvitis is of rare occurrence in adults, except
as an epidemic affection in connection with some types of puer-
330
A TEXT-BOOK OF GYNECOLOGY.
peral fever. It has been met with as a complication of the zymotic
diseases in cachectic children. In either case it is an indication
of great depreciation of the vital forces and is often fatal.
The gangrenous invasion begins as a grayish, reddish or black-
ish vesicle, or patch, which ends in ulceration, induration and
mortification (Velpeau).
The treatment consists of sustaining measures and those
calculated to destroy the diseased area. The first implies the
judicious use of stimulants and the most nourishing and concen-
trated food; the second, the destruction of the gangrenous area
by the actual cautery or nitric acid. Disinfecting poultices, both
before and after the application of the cautery or caustic, are to
be used. The internal remedy should be directed toward the
constitutional affection.
Therapeutics of Vulvitis.
Aconite.-Vulva dry, hot and sensitive; painful urging to
urinate; urine scanty and scalding hot; more or less vascular
excitement with restlessness.
Belladonna.-Sensitiveness of vulva; burning pressure with
weight and throbbing pain in the uterine region; sensation of bear-
ing down.
Graphites.-Thin white leucorrhea, which is very profuse;
menses too late, or scanty and painful; ITCHING OF PUDENDA
BEFORE MENSTRUATION; swelling of the labia; papules on puden-
da, which give rise to much itching.
Sepia.-Soreness of labia, perineum, and between thighs, with
redness; sticking in pudenda; vulva feels enlarged; leucorrhea
after micturition, with itching in vagina; discharge of blood after
coition.
Cantharis. Swelling and irritation of vulva, with violent itching;
pruritus, with strong sexual desire; painful urination.
Consult:-Arsenicum, mer. cor., sulphur, apis, hamamelis,
hydrastis, lycopodium, platina, rhus tox., bromine and silicea.
PHLEGMONOUS INFLAMMATION OF THE LABIA MAJORA.
The labia majora are composed largely of adipose and areolar
tissue, which is liable to become inflamed. The various forms
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 331
of vulvitis may involve the deeper structures and end in phleg-
monous inflammation. It is oftener, however, due to direct
injury.
The symptoms follow, as in inflammation of similar structures
elsewhere, in pathological succession. There is first congestion,
succeeded by hardness and tension from effusion of liquor san-
guinis. The effusion may be absorbed or suppuration may ensue.
The pus is usually very offensive.
Diagnosis.-The disease commences with symptoms of burn-
ing heat in the affected area, followed by pruritus and exag-
gerated glandular secretion, which is often both offensive and
irritating. Pain of a throbbing or aching character soon super-
venes, which is aggravated by walking or the upright posture.
Suppuration is preceded by an indistinct chill. After the tumor
forms, care must be taken not to confound it with pudendal
hematocele, labial hernia, displaced ovary, or distention of the
Bartholinian glands.
Treatment.-An effort should be made to abort suppuration at
the onset by perfect rest, cold applications, and the administra-
tion of the indicated remedy (bell., hepar s., mercurius, apis). If
suppuration is inevitable it should be hastened by hot applica-
tions, and as soon as pus has formed the parts should be freely
incised. The peculiar character of the tissue involved usually
makes surgical interference necessary, for the abscess will be-
come very large before spontaneous discharge occurs, and may
even reach the abdominal ring through the dartoid sac.
INFLAMMATION AND ABSCESS OF THE VULVO-VAGINAL
GLANDS.
Any of the forms of inflammation of the external genitalia
already studied may extend to these glands or their ducts.
Gonorrheal Vulvitis is, however, the most frequent cause.
The duct is usually obliterated by the inflammatory process,
when the gland becomes distended. If suppuration ensues it
gives rise to more or less febrile disturbance. There is a beating,
throbbing pain in the parts, which become very sensitive to
contact or touch of any kind. Should suppuration not ensue
there is formed a painless tumor or cyst varying in size from a
332
A TEXT-BOOK OF GYNECOLOGY.
pigeon's to a hen's egg, which may remain dormant for an
indefinite period. I have removed these sacs after they have
existed for fifteen years. A non-purulent cyst is, however, liable
to suppurate at any time.
The swelling is located at the posterior portion of the labium
majus at its outer border, impinging upon the opposite side and
partially occluding the vaginal orifice. When both sides are
involved, which is the exception, the introduction of the finger
into the vagina may be difficult. When suppuration follows the
inflammation the pus may partially escape through the duct, the
abscess refilling and discharging indefinitely.
I am not aware that any of the authorities mention that cysts
of the Bartholinian glands may excite reflex phenomena. In a
case coming under my observation the patient had long been a
victim of severe attacks of migraine, for the relief of which she
was compelled to resort to morphin and had almost contracted
the opium habit. Both glands were enormously distended, and
their complete removal required quite an extensive and bloody
dissection. The incisions were closed by a continuous suture,
except at their lower border, and the oozing was controlled by
packing with iodoform gauze. It required some time for the
cavities to close by granulation, but from the day of the opera-
tion to the present time (six months) there has been no return
of the sick-headaches. As an isolated instance of the kind it is
interesting, though final conclusions should not be drawn from
a single case. We know so little of the actual modus operandi of
reflexes as at least to warrant us in recording isolated cases
when marked results follow the removal of a possible cause.
Treatment.—The same principles governing the treatment of
phlegmonous inflammation apply to this condition during the
period of active inflammation. After an abscess has formed, a
simple incision is hardly sufficient, for measures must be taken
to destroy thoroughly the secreting surface of the gland. This
can be done by packing the cavity with lint soaked in the tinc-
ture of iodin, but a more radical and satisfactory method is com-
plete dissection of the sac. In non-purulent cysts this is my
invariable practice, and I have many times done the operation
by the aid of cocain anesthesia. From five to fifteen minims of
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 333
a four
per
cent. solution should be injected under the skin in the
line of the incision, which should be parallel with the long axis
of the labium. By inserting the point of the hypodermic needle
midway between the two extremities of the contemplated incision
it can be pushed upward and downward in the superficial areolar
tissue, while the fluid is being gradually ejected in such a way
as to make but one puncture necessary. After waiting five min-
utes, an incision is made which exposes nearly the entire length
of the sac, and which makes its removal possible without rup-
ture. More cocain can be applied as the operation progresses
if it becomes necessary. Arteries requiring it should be tied
with fine catgut. The remaining cavity should be partially closed
from above, if very large, with a continuous suture, drainage
being provided for at the lower border; or it may be packed
with iodoform gauze. Because of the danger of contamination
from the urine I prefer to close all but the lower angle of the
wound. The dressings should be changed at least once a day.
In distention from closure of the duct any attempt to restore
the patulousness of the latter is utterly useless, as is also any
attempt to cure the cyst by simple incision. The secreting sur-
face of the gland must be destroyed, or it will rapidly refill, and
while this may be done by destructive agents applied to its
interior, the complete dissection is, in my experience, a much
more satisfactory and surgical-like procedure.
Therapeutics of Phlegmonous Inflammation of the Labia Majora
and Abscess of the Vulvo-Vaginal Glands.
Belladonna.—Burning pressure, with weight and throbbing
pain in the inflamed parts; bearing-down sensation.
Apis mel.-Deep, penetrating pain in clitoris, extending into
vagina, with swelling, dryness, and hardness of labia minora,
which is relieved by the application of cold water; pain in vulva,
associated with stinging, burning pain in ovarian region; ERYSIPE-
LATOUS INFLAMMATION, WITH MUCH EDEMA.
Hepar sulph.-Abscesses of the labia, which are very sensi-
tive, with splinter-like pains and extremely offensive leucorrhea
of carrion-like odor; useful either for preventing or promoting
suppuration.
334
A TEXT-BOOK OF GYNECOLOGY.
Mercurius sol.-Leucorrhea always worse at night; inflam-
mation of labia, with smarting, corroding, and itching; vulvitis,
especially of gonorrheal, or syphilitic origin, with rawness and
excoriation of the parts.
Silicea. Profuse, acrid, corrosive leucorrhea; burning in
pudenda, with eruption on inner side of thigh; pudendal abscess,
which does not readily heal, with thin discharge.
Consult:-Sulphur, rhus tox., pulsatilla, kreosotum, lache-
sis, borax, iodium.
PUDENDAL HEMORRHAGE.
Traumatic causes, such as kicks, falls, incisions, etc., may rup-
ture both the skin and the bulbs of the vestibule, thus permit-
ting alarming and even fatal hemorrhage to take place exter-
nally. The accident is not a frequent one, and the treatment
will depend upon the extent of the injury and the amount of
hemorrhage. If the quantity of blood escaping is not great,
cold applications, with pressure, may be all that is necessary.
If this fails astringents, such as the saturated solution of alum,
powdered tannin, or the persulphate of iron, should be applied.
If it is not affected by these agents, the vagina should be
plugged and the parts firmly compressed by the aid of a band-
age; or the wound enlarged and the bleeding surface packed
with styptic cotton. Surely no fatal hemorrhage ought to occur
from a wound of the kind if proper surgical measures are attain-
able. Nevertheless, there are several fatal cases of pudendal
hemorrhage recorded.
PUDENDAL HEMATOCELE,
By this term is meant a hematic tumor formed by the rupture
of the bulb of the vestibule, with an effusion of blood into the
surrounding tissue. It is met with much oftener in obstetric
than in gynecological practice, yet in the non-puerperal the same
causes which sometimes give rise to pudendal hemorrhage by
lacerating the skin may rupture the bulb alone. The largest
pudendal hematocele I have ever seen was the result of falling
astride a wagon wheel, the patient being very large and fleshy.
Symptoms.-The tumor varies in size from that of a walnut to
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 335
a fetal head. It is sudden in origin, though its full size may be
attained gradually. When it occurs as a complication of labor
it is more apt to take place during or immediately after the
expulsion of the child. At first the patient complains of noth-
ing more than a sense of discomfort, but as the tumor increases
in size pain and throbbing become prominent. Micturition may
be difficult or impossible because of the pressure. Touch will
reveal a tumor which, if very large, may obstruct the vaginal
orifice. The parts in the larger effusions sooner or later become
deeply discolored.
The course and termination are very variable, depending upon
the size of the tumor and, in no small degree, upon the treat-
ment resorted to. If the effusion is small, it usually becomes
entirely absorbed, or may remain almost indefinitely in the tis-
sues as an encysted mass. Suppuration is particularly liable to
follow parturition, in which event there is always great danger,
because of the exaggerated size of the veins and lymphatics at
this time, of septic infection. Secondary hemorrhage may ensue
from rupture of the sac.
In the treatment of pudendal hematocele an attempt should be
made: (1) to limit the effusion by rest, cold applications, and
the use of hamamelis, both externally and internally; (2) to pro-
mote suppuration, if inevitable, by hot fomentations, poultices,
etc., and the administration of hepar sulphur internally. The
abscess should be opened as soon as the evidences of pus pre-
sent themselves, and the cavity washed with a 1-3000 bichlorid
solution.
Occasionally a large tumor manifests no tendency either
to disappear or to suppurate, and operative interference becomes
imperative to relieve the patient of its presence. This consists
of a longitudinal incision sufficiently long to enable the operator
to turn out the clot. Hemorrhage is to be controlled by pressure,
if possible; if this fails, by packing the cavity, after thoroughly
washing it out with a 1-3000 bichlorid solution, with strips of
gauze saturated in liq. ferri perchlor. For reasons already
given, the dressings should be changed at least once every
twenty-four hours in non-puerperal, and even oftener than this
in puerperal cases.
336
A TEXT-BOOK OF GYNECOLOGY.
•
PUDENDAL HERNIA.
In order to understand how any of the abdominal viscera can
find their way into the pudenda it is necessary to revert to the
anatomy of these parts (Fig. 3). The pudendal sac, formed by
the deep layer of superficial fascia and the outer layer of triangu-
lar ligament, receives at its neck the terminal fibers of the round
ligaments of the uterus. The round ligaments are the analogues
of the spermatic cord in the male and the ⚫labia majora cor-
respond to the scrotum. Since the ligaments pass through the
inguinal canals into the abdomen, it is entirely possible for a
loop of intestine, a portion of the omentum, or even an ovary,
to descend into the pudendal sacs, thus constituting a hernia.
The causes are, as in the male, congenital weakness of the parts,
blows, falls, violent muscular efforts, coughing, sneezing, etc.
The symptoms do not differ essentially from those of hernia in
the male. There is greater danger, however, of mistaking
pudendal hernia for other conditions calling for the use of the
knife—hence the importance of careful exploration in all tumors
about the vulva before any cutting operation is resorted to.
In all cases of obstinate vomiting in the female, with symptoms
of intestinal obstruction, the pudendal, femoral, and inguinal regions
should be carefully explored. I have met with one case of strangu-
lation which had been overlooked by the attending physician,
notwithstanding that the patient vomited almost continuously for
three days. Fortunately, the strangulation was reduced by my
associate, Dr. A. I. Sawyer. In another neglected case in which
I was called as counsel the strangulation could not be overcome
and a successful herniotomy was resorted to.
When the contents of the sac consist of intestine and no
strangulation exists the patient will complain of pain upon
bending the body, which will direct her attention to the parts.
An examination will reveal the characteristic symptoms of
intestinal hernia-impulse upon coughing, resonance on percus-
sion, absence of inflammatory signs or those of edema, and
the possibility of diminishing the volume of the tumor by taxis.
If the sac contains omentum alone there is greater difficulty in
making a diagnosis, especially if it is adherent. Fortunately, a
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 337
mistake here would not be so serious, were a knife introduced,
as in case of intestinal hernia; it is one, nevertheless, that
ought not to occur. The ovary occasionally finds its way into
the pudendal sac, either congenitally or otherwise. The tumor
is very sensitive, especially at the menstrual period, and there is
a peculiar sickening pain upon pressure.
The treatment of pudendal hernia does not differ from the
treatment of scrotal hernia in the male. The hips should be
elevated by having placed under them a cushion, or by raising
the foot of the bed. Taxis should be exerted in an upward
direction in such a way as to carry the contents toward the
abdominal ring. After reduction a properly fitted truss should
be worn, so that the pad will press upon the inguinal canal close
to the point of exit.
If the hernia cannot be reduced by taxis, and strangulation
has occurred, operative measures should be instituted at once.
The technique of the operation is described in all text-books on
surgery, and requires no description at this time.
HYDROCELE.
Hydrocele is an exceedingly rare affection in the female. The
canal of Nuck is ordinarily obliterated in the adult female, which
accounts for the rarity of both hernia and hydrocele in women.
Excessive secretion of this serous membrane, which is a pro-
longation of the peritoneum, constitutes hydrocele. The ac-
cumulation may be either sacculated or free, depending upon
the perviousness of the abdominal opening. If the latter is
open the fluid can be forced into the abdominal cavity, as in
hydrocele of the male.
The symptoms of hydrocele are sometimes very obscure, and
careful differentiation is important. The diagnosis must be
reached by exclusion. The tumor develops gradually with
entire absence of pain or constitutional disturbance. Inflam-
matory symptoms are likewise absent, and the ordinary signs of
hernia-resonance, cough impulse, etc.—are wanting. There
may be translucency, but this is an exceedingly rare symptom.
In all cases of uncertainty a fine exploring needle may be used
with comparatively little danger.
22
338
A TEXT-BOOK OF GYNECOLOGY.
Treatment. This is conducted upon the same principles as are
observed in the treatment of hydrocele in the male. Simply
drawing the fluid off through an aspirator may be all that is
necessary. If this fails, the sac can be injected with a few drops
of carbolic acid. If failure again results, the radical operation-
cutting down and draining the cyst-may be done.* Apis
should be given internally.
EDEMA OF THE LABIA MAJORA AND NYMPHÆ.
This condition is always symptomatic, either of general ana-
sarca or of pressure upon the large vessels within the pelvis,
usually the result of pregnancy. The swelling pits upon pressure,
is usually symmetrical, and is tense and shining. There is but
little pain unless excoriation follows, and the only inconvenience
results from interference with sitting or micturition.
The treatment must be directed to the constitutional or me-
chanical cause responsible for the mischief. The heart, liver,
and kidneys should be examined, and if the edema occurs as a
complication of pregnancy, the urine should be carefully ana-
lyzed. If due to simple pressure, the horizontal posture should
be assumed as much as possible. Apis internally will do much
good, and is the remedy oftener indicated. Should the disten-
tion be great enough to interfere with parturition, superficial
punctures with a needle or scalpel may be made for the purpose
of liberating the fluid.
NEOPLASMS OF THE VULVA.
Almost any form of neoplasm may occur in this region. The
most common are those resulting from venereal infection-condy-
* Lammert (Munchener medicinische Wochenschrift, 1891) believes that gestation
and the puerperum are the most prominent predisposing causes of hydrocele in
women. The round ligaments during this time partake of the physiological hyper-
trophy of the uterus, and inflammatory irritation of the canal of Nuck is easily excited
by trauma or otherwise. He advises that small hydroceles be left unmolested. This
author believes, as does Gottschalk (Cent. f. Gyn., 1887), that the effusion of serum is
frequently the result of irritation caused by an escape of blood into the canal through
rupture of a small vessel. Gottschalk cites a case of three years' duration which was
mistaken for hernia and a truss worn during the entire time. Smital (Cent. f. Gyn.,
1891) removed six ounces of fluid from a hydrocele coming under his observation.
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 339
lomata lata and acuminata—yet fibromata, myxomata, lipomata,
enchondromata, neuromata, lupus, and the various forms of
malignant growths are occasionally met with.
The condylomata lata are usually found on or about the
perineum, in the region of the anus or on the inside of the
labia majora. They result invariably from true syphilitic infec-
tion. The condylomata acuminata, on the other hand, are oftener
due to gonorrheal infection, or to non-specific leucorrheal dis-
charge.
The treatment must be governed by the cause. If due to
syphilis, an anti-syphilitic régime should be observed. In simple
papillomata, thuja occidentalis, externally and internally, will
usually accomplish a cure without resorting to surgical measures.
They are, however, effectually destroyed by clipping them off
with scissors and touching their bases with strong nitric acid
or the Paquelin cautery.
Fibromata, myxomata, and lipomata are of rare occurrence.
Polaillon reports in the Annual of the Universal Medical Sciences
for 1892 an enormous fibro-myoma, the pedicle of which was
formed by the hypertrophied round ligament, which was as
large as the index finger. The rarity of these several forma-
tions makes a more extended description unnecessary. Their
greatest clinical importance lies in the fact that they may be
confounded with some one of the several conditions causing an
increase in the size of the vulva. By carefully observing their
clinical history this can usually be avoided.
Of the malignant growths epithelioma is the most common.
A most interesting case of epithelioma of the external genitalia
is shown in Fig. 63, which came under my observation at my
clinic during the college session of 1890-91.* There were no
signs of the disease three months previously to the patient's
entering the hospital, at which time she was being treated for
hemorrhoids. Her physician was so unfortunate as to spill the
fluid with which he was injecting the tumors (probably carbolic
acid), and it burned her severely. The accident was followed
by inflammation and ulceration, which took on a malignant type.
* North American Journal of Homeopathy, October, 1891.

340
A TEXT-BOOK OF GYNECOLOGY.
I removed the diseased area as completely as possible with a
Paquelin, and with the loss of no blood. The groin was thoroughly
FIG. 63.
EPITHELIOMA OF THE EXTERNAL GENITALIA. (Wood.)
emptied and the parts healed kindly, but in three months' time
she returned with a hopeless invasion of the disease.
The consideration of neuromata will be deferred until the
subject of vaginismus is dealt with. (v. page 341.)
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 341
TABLE SHOWIng the DiffeRENTIAL DIAGNOSIS OF PUDENDAL ABSCESS, HEMA-
TOCELE, HERNIA, HYDROCELE, Cysts of the BARTHOLINIAN Glands, EdemA
OF THE LABIA MAJORA AND NYMPHÆ, ANd Neoplasms OF THE VULVA.
NAME.
ONSET.
Causes.
SYMPTOMS.
Abscess.
Acute.
Inflammation,
trau-
matism, gonorrhea,
Pain, chilliness, fever, redness,
swelling, etc.
etc.
Hematocele. Sudden.
Hernia.
Sudden or
insidious.
Hydrocele. Gradual.
Cysts of the Gradual.
Bartholi-
nian glands.
Edema of la- Gradual.
bia majora
and nym-
phæ.
matism.
Parturition and trau- Sudden appearance of tumor,
at first painless; discolora-
tion; resolution or secondary
symptoms of suppuration.
May be congenital;
lifting, straining,
kicks, blows, etc.
Same as hernia; effu-
sion of blood into
canal of Nuck.
(Lammert, Gotts-
chalk.)
Impulse on coughing; reson
ance; absence of inflammatory
signs; effects of taxis; if sac
contains ovary; great sensitive-
ness and symptoms all aggra-
vated at menstrual period.
Absence of signs of hernia;
translucency; evacuation by
exploring needle and collapse
of tumor.
Any source of vulvar Absence of inflammatory symp-
irritation.
toms and signs of pus; ab-
sence of hernial signs; loca-
tion of tumor (backward);
exploring needle (the fluid is
much more viscid than that
of hydrocele.)
Systemic. Diseases
of heart, liver, or
kidneys. Pressure
resulting from preg-
nancy.
Neoplasms of Always grad- Often no definite cause
the vulva.
ual.
traceable.
General.-Symptoms of con-
stitutional lesion and general
anasarca; symmetry of swell-
ing; shining surface which
pits upon pressure; absence of
inflammation.
The only neoplasm liable to be
confounded with the condi-
tions included in this table is a
small non-malignant growth
(fibroma). The diagnosis can
usually be made by exclusion
as well as by the physical char-
acter of the growth. It is hard,
painless, and unyielding. In
all cases of doubt a fine aseptic
exploring needle may be used
with comparative impunity.
CHAPTER XXIII.
DISEASES OF THE EXTERNAL ORGANS OF GEN-
ERATION (Continued).
PRURITUS VULVÆ; HYPERESTHESIA OF THE VULVA.
Pruritus Vulvæ.-This is a symptom, more or less promi-
nent, of the various affections described in the preceding chap-
ter. It rarely, if ever, occurs as an independent affection, yet its
importance is such as to call for special attention.
Causes.-Thomas and Mundé classify the causes as follows :*
1. Contact of an irritating discharge.
Acute and chronic endometritis and vaginitis;
Discharge of cancer ;
Incontinence of urine;
Diabetes.
2. Local inflammation.
Vulvitis;
Urethritis;
Vaginitis;
Follicular ulcers.
3. Local irritation.
Eruptions of the vulva;
Animal parasites;
Onanism;
Vegetations on the vulva;
Vascular urethral caruncles;
Growth of short, bristly hair on mucous face of the
labia.
To the foregoing should be added the following predisposing
causes:
* "Diseases of Women," p. 145.
342
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 343
Pregnancy;
Sedentary habits ;
Depreciated general health;
Neurotic diathesis.
These various causes require no extended consideration. Irri-
tating discharges give rise to pruritus oftener than does anything
else. Those coming from the vagina and endometrium are the
most irritating, especially when they are due to chronic inflam-
matory trouble. Those cases of endometritis occurring and
continuing after the menopause give rise to a discharge which is
especially troublesome and obstinate. It must be borne in mind
that a very slight discharge may be responsible for the pruritus,
and this may proceed from the urethra, Skene's glands, or even
from the vulvo-vaginal glands (Mann). The scantiness of the
discharge may make it exceedingly difficult to discover its true
sources.
Attention has already been called to the importance of diabe-
tes as a causative factor in vulvitis. The irritating character of
diabetic urine is well known; consequently in pruritus vulvæ the
urine should always be examined for sugar.
Of the various forms of vulvitis the follicular-possibly
because it occurs oftener in connection with pregnancy-is
attended with the severest type of pruritus. All of the eruptive
diseases give rise to more or less itching, as they do when occur-
ring in any part of the body. As observed by Thomas, "the
natural warmth of the parts, formed as it is by folds of tissue
and covered by hair which is thickly interspersed with sebaceous
and piliferous glands, makes them more likely to prove active in
causing it."
The parasites sometimes responsible for this symptom may be
of the animal (pediculus pubis, acaris scabiei, oxyuris vermicularis),
or of the vegetable variety (leptothrix vaginalis, oïdium albicans).
It is maintained that the former varieties may act in a reflex
way as well as by direct contact. The vegetable parasites are
very rarely met with in this locality.
Growth of short, bristly hair on the mucous face of the labia
oftener results from some local disease, especially eczema, which
modifies the nutrition of the parts.
344
A TEXT-BOOK OF GYNECOLOGY.
Pruritus vulvæ occasionally occurs as a purely neurotic affec-
tion. That is to say, itching may be present in its most intense
form without any discoverable causes or lesions. This form of
pruritus oftener occurs in conjunction with pregnancy, and may
extend down the thighs and over the entire surface of the abdo-
men. The extensive area involved cannot be due to direct
inoculation through scratching, for in most instances there is an
entire absence of secretion. It is essentially neurotic when
manifesting itself in this form, and is much more apt to occur in
women of neurotic temperament.
Pathology. To whatever cause the pruritus may be due, there
is exaggerated irritability of the nerves supplying the parts in-
volved. This change consists, according to Webster,*" of a slowly
progressing fibrosis of microscopical proportions, especially of
the nerve and nerve endings of the clitoris and labia minora."
This writer maintains that many of the nerve-fibers are com-
pressed or destroyed by the dense, fibrous character of these
changes. In harmony with these views, he practises the
thorough removal of the affected part in order to cure the dis-
ease.
Symptoms.—The intensity of the symptoms will depend
upon the nature of the cause and the temperament of the
patient. The itching is aggravated by exercise and especially
by the warmth of the bed. In the severer forms the patient
cannot refrain from scratching, which only intensifies the distress,
irritating and lacerating the parts. Leucorrhea is so commonly
associated with pruritus that it is many times difficult to deter-
mine whether it is the primary cause or the result of the vulvitis
excited by scratching the parts.
Treatment.—It is unnecessary to remind the reader that if any
of the causes enumerated exist they must receive attention. If
removable, very good; if not, measures must be taken to pro-
tect the parts from contact with them. It is often imperative,
too, temporarily to palliate the existing suffering, and for this
purpose some form of local application is indispensable.
The parts should be protected from irritating discharges by a
* Edinburgh Medical Journal, 1891.
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 345
medicated tampon placed in the vagina; or by applying to them
some of the powders or unctuous substances recommended
for the same purpose in the various forms of vulvitis. An
effort should, of course, be made to cure the discharge by attack-
ing the seat of the catarrh. Animal and vegetable parasites
should be destroyed-the former, when occurring upon the
pubes, by ungt. hydrargyri, or by a bichlorid wash (grs. iij−3j).
Ascarides must be attacked through the rectum. The vegetable
parasites are best destroyed by a solution of borax (3j-3j). If
short, bristly hairs are found upon the mucous surface of the
labia these should be removed with fine pincers. The general
management of cases due to depreciated general health and
sedentary habits naturally suggests itself to the practitioner.
The curative treatment is both local and general. As regards
local measures, I can but second the words of Dr. Ludlam :* “
"It
would be cruel to deny our patient such palliatives as will miti-
gate her sufferings without the least interfering with the cure of
her complaint." Indeed, I claim more for many of the appli-
cations than mere palliation, for I am convinced that they hasten
the cure while at the same time they afford temporary relief.
More than once patients with pruritus vulvæ have come to me
from the hands of other physicians because local expedients had
been denied them. It is true that in using local measures we
cannot do so with any degree of precision. There are no
specific indications for a given application in a given case, and
in the larger proportion of instances the use of local applica-
tions is purely empirical. As a result, almost countless num-
bers of formulæ are given by various writers, and almost
countless numbers are at times necessary before one can be
found that will mitigate the terrible suffering sometimes present.
When the pruritus occurs in its worst form there are few women
who, if relief is not afforded, possess sufficient resolution to re-
frain from going from one physician to another. I therefore
follow in the footsteps of my predecessors and give to the reader
several formulæ to draw from. I have simply selected those
which appeal to my judgment, or with which I have had per-
*" Diseases of Women," 6th edition, p. 532.
346
A TEXT-BOOK OF GYNECOLOGY.
sonal experience. The properly selected internal remedy is all
important and should be sought for with care and discrimina-
tion.
Previously to the use of any local application the parts should
be thoroughly washed with pure castile soap or, better still,
juniper tar soap. The diet should be non-stimulating and the
clothing not too warm. Any one of the following applications
may then be made as frequently as the severity of the symp-
toms calls for :-
R. Hydrarg. bichloridi,
Tr. opii,
Aquæ,
•
S. For external use only. (Thomas and Mundé.)
R. Acidi hydrocyan. dil.,
Plumbi diacetatis,
Olei cacao,
•
.. 3 ss
3j
3 viij.
•
S.-Apply after washing with cold water. (Thomas and Mundé.)
R. Chloroformi, .
Olei amygdalæ expressi,
S.-Apply to the itching parts. (Goodell.)
R. Acidi acetici,
Glycerinæ,
S.-Apply locally. (Goodell.)
R. Sodii boratis,
Morphiæ muriatis,
Acidi hydrocyanici, dil.,
M.
zij
Dj
·
3ij.
M.
•
3j
3j.
M.
3j
3iij.
M.
NO NO
•
•
z ij
grs. xx
3i
Aquam rosæ, ad. .
S.-Apply with soft sponge. (Goodell.)
R. Acid. tannici,
Extra, belladon.,
Butyr. cacao,
Div. in suppositories No. xx.
S.—Insert one into the vagina night and morning. (May.)
R. Chlorali,
Camphoræ,
·
Rub these into an oil and then add
Unguenti simplicis,
Pulv. acidi borici,
·
S.-Apply with a brush. (Goodell.)
3 viij.
M.
· zij
gr. x
3 v.
M.
āā . . . 3 iv
3j
ziv.
M.
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 347
R. Aluminii nitratis,
Aquæ destillatæ, .
S.-Apply with soft sponge. (Gill.)
R. Cocain hydrochloratis,
Unguenti petrolei,
S.-Apply to the itching parts.
B. Potassii cyanidi,
Liquoris calcis,
Adipis, .
S.-Apply locally. (Goodell.)
•
gr. vj
3j.
M.
grs. iv-vj
3j.
M.
gr. j-iij
3 iv
3 iv.
M.
מא מא
For vaginal injections the following are recommended by
Professor Thornburn.* The figures attached to each indicates
the quantity to be used per ounce :—
Acid carbolic, gr. x and upward.
Liq. plumbi acetat., 3 ss.
Acid. boracic, ad, sat.
Acid hydrocyanici, dil., mx.
Sulpho-carbolate of zinc, gr. x.
Sulphurous acid, 3j.
Dr. Skene recommends the following:† A powder composed
of one grain of morphin to two grains of chalk, to be applied
night and morning; equal parts of the tincture of opium, iodin,
and aconite; iodoform in ether applied by means of an atomizer ;
carbolic acid and iodin, equal parts.
I again quote from Ludlam: "If there is a vesicular eruption
with a raw surface, or the burning in the urethra and the
dysuria are very marked, water or glycerin or both may be
medicated with the tincture of cantharis and applied to the vulva
by means of compresses.
The urtica urens is appropriate to the erythematous form,
with a scarlet surface of the mucous membrane, and where there
is complaint of burning and stinging as from nettles.
"In case of aphthous ulceration . . . . common borax and
hydrastis are in excellent repute as palliatives
*"A Practical Treatise on the Diseases of Women." London, 1885.
+ "Diseases of Women," p. 96.
‡ Op. cit.
348
A TEXT-BOOK OF GYNECOLOGY.
Alexander Duke* recommends penciling the parts with
menthol cones.
Von Campe† records the following case :—
"The patient, aged fifty-three, suffered for two and a half years from intense
irritation of the vulva, perineum, and groin. Various and numberless remedies
had been tried in vain-the sensitive portion of the skin and mucous membrane
having been excised. A cessation of all symptoms occurred in two days following
the use of the constant current, the anode being applied to the vulva and the cathode
to the various other parts affected.”
I used the constant current with marked success in one case
of pruritus vulvæ. The patient was of the neurotic type and
the itching, of long duration, was very severe. The labia were
more or less thickened as the result of scratching, and there
was some uterine discharge caused by a retroflexion of the
uterus. This entirely ceased after the organ was straightened
by the Alexander operation, and I could then discover no cause
to account for the irritation. In a fit of desperation, and before
I had seen any recorded instance of the use of electricity for
this condition, I resorted to galvanism. The dispersing nega-
tive electrode was applied to the abdomen and the positive, by
means of a metal electrode, to the parts affected. A current of
fifteen milliampères was as strong as the patient could tolerate.
These applications were made every other day for two weeks,
when the symptoms entirely disappeared. Four years have
now elapsed and there has been no return of the disease.
In another patient the pruritus entirely disappeared while
using the stronger current (50 milliampères) for the purpose of
absorbing pelvic adhesions. Direct applications were made by
means of an intra-vaginal electrode. There was much thicken-
ing of the nymphæ and labia, which subsided as the treatment
progressed.
Therapeutics.
Sepia.-Severe itching of the vulva with swelling and eruption
of the inner labia; painless vesicles in the outer part of the
vulva; violent stitches sometimes extending as far as the
umbilicus.
* Annual of the Universal Medical Sciences, 1892.
† Ibid.
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 349
Graphites.—Itching and smarting of vulva; painful soreness
between the vulva and thighs, the parts being covered with pimples,
vesicles, and ulcers; menses too late, too scanty, and too pale;
moist eruptions on various parts of the body.
Rhus tox.-Eczema of the vulva with much burning and
itching; relief from change of posture.
Cantharis.-Pruritus associated with frequent desire to urinate,
with burning pain on passing a few drops, or completely strangury.
Mercurius.-Greenish, offensive leucorrhea, always worse at
night, with smarting and burning after scratching; sensation of
rawness; salivation, soreness of the gums, teeth, etc.
Lycopodium.-A great deal of itching of the parts after
menses; much restlessness at night.
Kreosotum.-Violent itching of the labia, also of the vagina ;
external genitals are swollen and excoriated from contact of
acrid discharge from above; leucorrhea of a yellow color, stain-
ing linen yellow, with great weakness.
Sulphur.-Burning in the vagina; troublesome itching of the
genitals with papillary eruptions about them; flushes of heat,
faint spells, etc.
Conium.-Pruritus extending into vagina; violent itching in
the vulva and vagina, especially after menses; leucorrhea with
weakness and paralyzed sensation in small of back before the
discharge.
Collinsonia. Especially during pregnancy or when associ-
ated with hemorrhoids, constipation, or other rectal troubles.
Arsenicum.-Vesicular or dry, scaly eruptions with a gan-
grenous tendency; worse at night; better from warmth and
warm applications.
Consult:-Ambra, caladium, carbolic acid, petroleum, nitric
acid, kali bromatum, silicea, and carbo. veg.
Hyperesthesia of the Vulva.-This condition consists of an
abnormal sensitiveness of the sensory nerves supplying some
portion of the vulva. The affected area may be limited
to the meatus urinarius, to one labium majus, or to the vesti-
bule, or it may implicate the entire vulva. It possesses none of
the characteristics of a true neuralgia, and seems to be due
entirely to a hyperesthesia of the sensory nerves.
350
A TEXT-BOOK OF GYNECOLOGY.
Frequency. The profession is indebted to Thomas* for the
first description of this disease. I have never yet seen a case,
and Mundé, whose experience has certainly been exceptionally
great, has never met with one.† The authorities generally agree
that the disease is not of frequent occurrence. I shall therefore,
in this brief description, draw largely from the original article of
Thomas.
Causes. In many instances no cause whatever can be dis-
covered. Occasionally it can be traced to irritable urethral
caruncles and to chronic vulvitis. Hysteria and hypochondri-
asis act as predisposing factors, and Thomas has met with it
oftener at or about the menopause.
Pathology. The condition is characterized by a "plus state
of excitability" in the sensory nerves. There is an absence of
inflammation, an absence of pruritus, and a physical examina-
tion "reveals nothing except occasional spots of erythematous
redness scattered here or there." The affection, in its uncom-
plicated form, is one of simple hyperesthesia of the diseased
nerves.
Symptoms.—Dyspareunia is the one symptom which, in the
vast majority of instances, leads the patient to seek medical
advice. This is in most cases absolute, and any attempt at inter-
course gives rise to the most excruciating suffering. In the
worst cases, the slightest friction or even a current of air strik-
ing the parts is sufficient to excite pain. The general health is
affected out of all proportion to the local manifestations, and
great mental depression not infrequently occurs.
Treatment.- Judging from the experience of Thomas and
others with local measures, I should be disposed, were I to meet
with a case, to rely almost entirely upon symptomatic treatment.
Galvanism might be of service, though I am unable to find any
recorded evidence bearing upon this point. The local sedative
effect of the positive pole ought to be useful. Thomas has
destroyed the sensitive area with nitric acid, has dissected off all
of the sensitive tissue, and yet affirms: "I have met with a num-
ber of cases of marked character, and in not one was complete
*" Diseases of Women," p. 145, 1880.
"Diseases of Women," Thomas and Mundé, p. 151, 1891.
DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 35I
relief given by treatment." He recommends: a change of air
and surroundings; the use of general tonics, as arsenic, strych-
nin, quinin, and iron; the removal of existing local lesions—
vulvitis, urethral vegetations, etc.; frequent ablutions with warm
water, followed by the use of local sedatives-opium, carbolic
acid, chloroform, belladonna, iodoform, cocain-and that the
patient live absque marito.
We do not have to contend with the same urgency of symp-
toms here as in pruritus vulvæ-hence temporary relief is not so
important. In view of this fact, and because of the unsatisfactory
results obtained by Thomas, who relied almost entirely upon local
therapeutic measures, our greatest reliance should be placed
upon the carefully selected remedy.
Therapeutics.
Platina.-PAINFUL SENSITIVENESS
AND PRESSURE IN THE
REGION OF MONS VENERIS, GENITAL ORGANS AND NYMPHÆ; ting-
ling or titillation from genitals up into abdomen; frequent sen-
sation as if menses would appear; menses too profuse and too
short lasting; flow dark and clotted, preceded by spasm and much
bearing down; pruritus vulvæ with anxiety and palpitation of
the heart; vulva painfully sensitive during coitus.
Belladonna.-PRESSURE DOWNWARD AS IF ALL OF THE CON-
TENTS OF THE ABDOMEN WOULD ISSUE FROM THE VULVA; clutch-
ing or clawing pains in the uterine region; parts sensitive;
cannot bear least jar; great heat and dryness of vagina.
Cimicifuga. Bruised feeling in vagina; sensitiveness of
uterus; menorrhagia; grieved, troubled and sighing, alternating
with cheerfulness; ovarian neuralgia, especially of left ovary;
pain extends up and down left side with great tenderness.
Gelsemium. Ovarian irritation with hyperesthesia of vulva;
uterus feels as if squeezed by the hand; menses suppressed with
passive congestion to the head.
Ignatia.-Violent labor-like pains in uterus, followed by puru-
lent corrosive leucorrhea; cramp-like pains in uterus, worse
from touching the parts.
Consult :-Cocculus, coffea, zincum, nux vomica, thuja, mag-
nesium phos., and kali brom. v. also Therapeutics of Pruritus
Vulva and Vulvitis.
CHAPTER XXIV.
VAGINISMUS; COCCYGODYNIA.
Vaginismus.-The muscles of the pelvic floor, any or all of
them, may contract spasmodically. The form of spasm under
consideration is defined by Sims, who coined the word "vag-
inismus," as "an excessive hyperesthesia of the hymen and
vulvar outlet, associated with such involuntary spasmodic con-
traction of the sphincter vaginæ muscle as to prevent coition.”
Catrin and Molènes applied to the same condition the term
vulvismus.
Pathology.-The greatest difference of opinion prevails re-
garding the pathology of vaginismus. Tait goes so far as to
contend that the so-called sphincter vaginæ muscle (com-
posed of the vulvi cavernosi muscles), exists only in imagi-
nation, or, if it does exist it is made up of a few bundles of
muscular fibers, and is, therefore, utterly incapable of acting as a
constrictor of the vagina.* He admits, however, that the
symptoms referred to are common enough, but does not under-
take to explain what muscles are contracted in the spasm.
The prevailing confusion is probably due to the fact that there
are several classes of causes. The classification made by Mann †
seems to me the best yet given. He divides the cases into three
classes. In the first class the cause is to be found in some
pathological lesion in or about the vulvar outlet; in the second,
the seat of irritation causing the reflex spasm of the muscle is
found to be in distant organs,-the uterus, ovaries, or rectum;
while in the third class no local lesion can be found and the
cause must be sought for in the nervous system.
In the first class the anatomical changes usually observed are
lesions of the hymen, erosions, fissures, redness, swollen
*" Diseases of Women and Abdominal Surgery," p. 78, 1889.
"American System of Gynecology, vol. 1, p. 511, 1887.”
352
VAGINISMUS: COCCYGODYNIA.
353
follicles and, frequently, papillary excrescences at the navicular
fossa (Schroeder). Sims believed that in the majority of instances
the lesion is located at the base of the hymen, oftener at the
margin nearest the urethral commissure. These several lesions.
may result in various ways. The trouble not infrequently dates
from marriage, and it is probable that some partial obstacle to
intercourse on the part of the woman (small vulvar orifice or a
rigid hymen) is responsible for the difficulty. Other obstacles
to sexual intercourse are, an abnormally high location of the
vulva, so that the penis presses the meatus against the pubes
and injures it, and a disproportion between the size of the male
and female organs. At any rate, difficult or painful cohabitation,
from whatever cause, may in time induce any of the enumerated
lesions, which in turn give rise to reflex spasm.
In the second class of cases the disease does not come on
until after sexual intercourse has been frequently performed, and
oftentimes the woman has given birth to one or more children.
Any lesion of the more remote organs may inaugurate the
reflex spasm. Such are: diseases of the rectum (hemorrhoids,
fissures, parasites, etc.); ovarian inflammation or displacement;
lacerations of the cervix and inflammatory diseases of the
uterus. Of these several causes I consider lesions of the rectum
of first importance. There is such intimate sympathy existing
between all of the pelvic organs that in an obscure disease like
vaginismus the rectum should always be examined.
Finally, a different explanation must be given in the third
class, where neither local nor remote evidences of disease are
found to account for the difficulty. The victims of this form of
vaginismus usually possess a nervous temperament, and are
frequently hysterical. In one of the worst cases of this kind
that I have ever met with the patient was nymphomaniacal.
Just why the spasm should occur under the circumstances it is
hard to say. The explanation offered by Sims, and accepted by
most authorities, is the following: An ineffectual or painful
attempt at intercourse gives rise to nervous apprehension on the
part of the woman, so that subsequent approaches of the male
result in nervous excitement and an involuntary contraction of
the levator ani and constrictores cunni muscles.
23
354
A TEXT-BOOK OF GYNECOLOGY.
The larger number of cases are undoubtedly due to the first
class of causes, a tender or hyperesthetic condition of the
hymen being oftener responsible for the difficulty than any-
thing else.
Symptoms.-The chief symptom is that of spasm of the
muscles of the pelvic floor, excited especially by attempts at
sexual intercourse. The spasm usually gives rise to pain, often
very intense, and after several attempts at intercourse the
approaches of the male result in such a degree of nervous
apprehension as to make further effort impossible. If digital
examination be attempted in the worst cases the spasm and pain
are at once exhibited, and it becomes utterly impossible to insert
the finger into the vagina. In several cases seen by me the
vaginismus was not so decided as this, giving rise to hindrance,
though not absolutely preventing, sexual intercourse. The finger
could be passed into the vagina, but an evident spasm was brought
on by indagation. I have had patients almost throw them-
selves from the table immediately upon touching the parts.
Barnes has seen cases where convulsions and syncope were
excited by attempted intercourse, and Thomas reports a case in
which washing the genitals, or even a sudden change of position,
was sufficient to bring on the spasm. On the other hand, Mann
has seen instances where an examination, even with the specu-
lum, failed to provoke a spasm, yet the introitus vaginæ tightly
closed on each attempt at intercourse. In another case observed
by the last named author coitus was impossible, notwithstanding
the fact that the patient could herself introduce the largest-sized
Sims dilator. In all of Mann's cases there was undoubtedly a
nervous basis for the vaginismus.
The prognosis is usually favorable if proper treatment is
resorted to; without treatment there is a tendency for the disease
to continue indefinitely. Pregnancy and parturition do not
always cure it, and the practice recommended by Sims of per-
mitting coitus under ether narcosis is to be condemned. The
purely nervous cases are the most difficult to cure.
Treatment.-There is no question in my mind regarding the
efficacy of the homeopathic remedy in the treatment of this
condition. It is probable that in the majority of instances some
VAGINISMUS: COCCYGODYNIA.
355 ·
surgical procedure will have to be resorted to before the cure is
complete, but in the newly married it is my practice to try
internal medication first. This is emphatically the thing to do
where no local causes are discernible and when the nervous
element stands out prominently. A little good advice should
be administered with the remedy, for it is surprising how dense
is the prevailing ignorance on the subject of marital relations.
In the class of cases alluded to the wife should occupy a sepa-
rate bed for at least a week or ten days, during which time
frequent sitz baths are to be taken. If there is very great
sensitiveness of the parts a suppository containing one grain of
cocain should be passed into the vagina night and morning.
It is a good plan to smear the parts with a ten per cent. cocain oint-
ment before intercourse is again attempted, which attempt should
be made with the utmost gentleness and care. If accomplished
without pain the nervous terror is largely done away with, and sub-
sequent attempts, which should be made at lengthened intervals,
are usually successful.
Failing to relieve the disease by this method, a more radical
one becomes imperative. What this shall be must depend upon
circumstances. As has been seen, the most frequent lesions are
found at or about the seat of the hymen or its remains (carun-
culæ myrtiformes). By touching the sensitive area with the
finger or a fine probe the spasm and pain are at once produced.
When this condition presents itself there is but one satisfactory
way to proceed, and that is to remove the entire mucous
membrane covering the diseased surface. This is done by
bringing the patient profoundly under the influence of an
anesthetic, exposing the hymeneal area with a Sims speculum,
and, with a tenaculum and curved scissors, removing it in one
continuous strip. Should there be any spurting arteries these
are compressed or, if necessary, tied with fine catgut. The
vagina is next thoroughly stretched with two Sims specula,
or with a large bi-valve rectal speculum. After this is done
the separated edges of the mucous membrane should be
brought together with a continuous catgut suture and the op-
posing walls of the vagina kept separated with iodoform gauze.
Sims devised for this purpose his well-known dilator (Fig. 64)
356
A TEXT-BOOK OF GYNECOLOGY.
which is to be kept in the vagina, after his cutting operation, for
some days. I do not like it, for it not only gives rise to much
suffering, but dams up the discharges and interferes with the
healing of the wound. Subsequently, after the parts are per-
fectly healed, these dilators may be advantageously used by the
patient herself in order to maintain a patulous condition of
the canal. Any other traces of disease at or about the vulva
should be looked after, the urethral orifice being carefully
inspected. If urethral vascular tumors exist they should be
snipped off with scissors and their bases touched with the actual
cautery. The rectum should next receive attention. My ob-
servation has been that, in most cases of vaginismus, there is
constipation with more or less spasm of the sphincter ani mus-
FIG. 64.

TIEMANN-CO-NY
SIMS'S VAGINAL DILAtor.
cles. It is my practice, therefore, to divulse the rectum at the
same sitting, and to remove any disease of this organ that may
exist. In one case previously operated upon without success by
a well-known gynecologist, who limited his operation to the
vagina, I succeeded in curing perfectly both the vaginismus and
the constipation by simple divulsion of the vagina and the
rectum.
Where no local causes are found, and the case is essentially
neurotic in all of its aspects, I wish to emphasize two things
essential to successful treatment: First, the constitutional treat-
ment is of the greatest importance, and should be carefully
looked after in all of its details; secondly, when divulsion is
resorted to, let it be done in the most thorough manner.
In-
complete divulsion is worse than useless, and I am confident that
VAGINISMUS: COCCYGODYNIA.
357
failures often result from an unnecessary fear of overstretching
the parts. The irritable muscle must be paralyzed, to accom-
plish which a considerable degree of force is necessary.
In case of disease or displacement of the organs above the
vagina, due attention must be paid to them. I once had to
do in my clinic with a case of vaginismus which was most
obstinate, though not absolute, and which was due to an exceed-
ingly excoriating discharge from the uterus. The acridity was
so great as to cause excoriation of the male member after inter-
course. There was a flexion of the uterus with obstruction,
which kept the secretions pent up. This case was ultimately
cured by divulsing the cervix, thus establishing free drainage of
the uterus.
Sims's operation for vaginismus is a much more bloody one
than that given, and seems to me an unnecessary mutilation.
It consists of a deep cut made with a scalpel through the vaginal
tissues on either side, terminating at the raphe of the perineum.
A third incision is extended directly backward through the peri-
neal raphe, completing the lower part of a Y. The vertical
incision is about an inch deep. The parts must be kept dilated
with the Sims dilator until perfectly healed.
Therapeutics.
Belladonna.-The spasms come on suddenly and disappear
with equal suddenness; a sense of heat and dryness is felt in the
parts.
Platina. Spasm and constriction of the vagina in nervous
women with great hyperesthesia of the parts; depression of spirits,
anxiety, and palpitation of the heart; nymphomania.
Caulophyllum.-Excessively irritable vagina; intense and
continued pain and spasm.
Cocculus.-Aggravated at every menstrual period; much
weakness and prostration during menses.
Magnesium phos.-Vaginismus with neuralgic pains in back,
which are darting, boring, and remitting in character.
Ferrum phos.-Vaginismus associated with throbbing pain
and congestion of the parts; symptoms made worse by motion ;
dysmenorrhea, with hot, flushed face, and quick pulse.
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A TEXT-BOOK OF GYNECOLOGY.
Cimicifuga.-Intense intermitting, neuralgic-like pains, at-
tended with cramps in lower limbs.
Berberis.—Intense pain in vagina, with burning and soreness
as if excoriated.
Consult:-Causticum, conium, kreosotum, mercurius, nux
vomica, and nitric acid.
Coccygodynia.-This name signifies pain in the coccyx. It
is one of the causes, and a very frequent one, of so-called “pain-
ful sitting" (Duncan). The affection is of quite common occur-
rence and calls for careful consideration.
Anatomy.—The coccyx is formed by the four last rudimen-
tary vertebræ of the spine. It juts sharply forward, forming an
obtuse angle with the sacrum. The sacro-coccygeal articula-
tions permit of a limited degree of backward movement during
defecation and parturition. Through disease, or because of
changes resulting from advancing years, ankylosis occasionally
occurs.
It serves as a point of attachment for the sphincter ani, leva-
tores ani, some of the fibers of the glutei, and the ischio-coccygei
muscles. The greater or lesser sacro-sciatic ligaments are also
attached to it (Fig. 2). These various structures are called
into play during the acts of sitting, standing, and defecation.
If the bone is diseased, or its surrounding structures hyper-
esthetic, these several acts reveal the condition under considera-
tion.
Causes.-Coccygodynia occurs either as a symptomatic or an
idiopathic affection. Any of the diseases of the genital organs
or of the rectum may give rise to it. When symptomatic of dis-
ease of these organs all evidences of lesions of the bone itself
will be wanting. The most frequent cause is traumatism-
kicks, falls, horseback riding, etc.-and the injuries resulting
from parturition. In a total of twenty-four cases observed
by Scanzoni, nine were caused by delivery. It is more apt to
occur in primiparæ somewhat advanced in years. Two cases
coming under my observation were the result of falling down
stairs, the buttocks striking upon the steps. While by far the
larger per cent. of coccygodynias are met with in women, it is
1
VAGINISMUS: COCCYGODYNIA.
359
by no means confined to them, men and even small children oc-
casionally suffering from the affection.
Pathology. This, as suggested by the causes enumerated,
is variable. In perhaps the majority of instances inflamma-
tion and necrosis are wanting. Luxation is found in a goodly
number of cases, but luxation does not always give rise to
pain. In examining one hundred and eighty pelves, Hyrtl
found thirty-two cases of luxation and ankylosis. This is a sur-
prisingly large per cent., and far exceeds the ratio of frequency
of coccygodynia. The most distressing cases that result from
luxation occur when the bone is directed backward and becomes
fixed. Periostitis and necrosis of the bone sometimes develop,
when the local evidences of disease can be discovered.
abscess may form as a result of the inflammation.
condition is symptomatic of lesions of neighboring organs the
pain is probably due to hyperesthesia of the tendons, or the
tendons may be the seat of rheumatic disease; at least, pain
in this region is sometimes associated with lumbago, and is
more apt to occur in the rheumatic and neuralgic diatheses.
An
When the
Symptoms. Any movement causing a sudden contraction of
the structures attached to the coccyx will, if the bone or its
surrounding structures are diseased or hyperesthetic, give rise
to acute pain. It is often most intense during the act of defeca-
tion, and care must be exercised in distinguishing it from pain
due to rectal disease or a displaced ovary. It is aggravated by
walking and by sitting. Sometimes the latter act is impossible,
or the patient is compelled to rest one buttock on the edge of
the chair in such a way as to protect the tender bone from
pressure. If there is a history of an injury, or if the symptoms
enumerated follow parturition,* coccygodynia should always be
suspected. These suspicions may now be confirmed or banished
by placing the patient upon her side and grasping the bone be-
tween the forefinger in the rectum or the vagina and the thumb
externally. If the symptoms result from coccygodynia, move-
ment of the bone will excite intolerable suffering. If the bone
*"I have more than once heard this joint snap, during labor, with a sound so loud as
to be heard some distance from the bed.”—Goodell.
360
A TEXT-BOOK OF GYNECOLOGY.
itself, or its periosteum, is involved, there is also tenderness on
external pressure.
The differential diagnosis will have to be reached by exclusion.
Existing diseases of the rectum, vulva, vagina, or uterus
which might give rise to similar symptoms should be sought
for. Lesions of the rectum are not infrequently confounded
with coccygodynia, and, indeed, lesions of that organ often ex-
cite true coccygodynia, as has been shown. In all instances of
the latter affection, whether reflex in origin or due to actual dis-
ease of the bone, the pain is excited by manipulation in the manner
described.
Goodell maintains that the coccygeal joint is quite as liable to
become hysterical as is the knee joint.* A differentiation here
is sometimes exceedingly difficult. The hysterical affection is
usually characterized by those erratic manifestations of pain which
stamp the character of hysteria wherever found.
The prognosis necessarily depends upon the cause of the dis-
ease, though with proper treatment it is usually favorable.
Treatment. The cause must be sought for and removed if
possible. The rheumatic and neuralgic cases are best reached
by internal medication. Sometimes galvanism is exceedingly
useful, and I have more than once succeeded in relieving the
pain by passing a twenty milliampère current through the
parts. This may be done by using the negative pole direct,
either in the vagina or rectum, and a large dispersing positive
electrode over the coccyx and the lower surface of the sacrum.
Galvanism will at least afford temporary relief in most instances
where the bone is not actually diseased.
If the pain persist in spite of the more conservative measures,
there are two operations, one or the other of which usually
proves successful. The first is the subcutaneous separation of
the ligaments as proposed by Simpson. A tenotomy knife is
inserted under the skin at the tip of the coccyx and carried to
its base. The muscular and tendinous attachments are completely
severed from the bone on either side before the knife is with-
drawn. If for any reason this procedure is difficult or impossi-
* "Lessons in Gynecology," p. 96.
VAGINISMUS: COCCYGODYNIA.
361
ble the method of Thomas may be practised. This author
makes an incision extending the entire length of the coccyx,
grasps the tip of the bone, and separates the attachments with
scissors. A still more radical measure is that of Nott, and is
indicated if the operations of Simpson and Thomas fail to
cure the disease, or if the bone is necrosed. The coccyx is laid
bare, disarticulated, and removed. This is not a difficult opera-
tion and can be done by any surgeon possessing a modicum of
skill. The edges of the wound should be coaptated and a
drainage-tube left in for several days. Because of the close
proximity to the rectum it is best to use antiseptic injections
until the discharge ceases. Total extirpation affords complete
relief in almost every instance.
Therapeutics.
Magnesium phos.-Sudden, piercing pain in coccyx; sud-
den, violent, concussive, tearing, stitching pain in the region as
if the coccyx were bent backward.
Cicuta vir.-Tearing, jerking in the os coccygis, especially
during menses; painful feeling of stiffness in the muscles of the
lower limbs; general prostration; bruised sensation throughout
the body.
Lachesis. Continual pain in sacrum and coccyx; pain in
small of back, as if sprained, hindering motion; agonizing pain
when rising from a chair.
Belladonna.-Intense, cramp-like pain in small of back and
os coccygis; relieved by standing or walking slowly.
Causticum.-Dull, drawing pain in the region of coccyx;
every movement of the body gives a pain in the small of the
back.
Graphites.-Violent itching of the coccygeal region, the
parts being moist with scurfy eruption; dull drawing in the
coccyx in the evening.
Mercurius. Tearing pain in the coccyx; worse at night;
pain in the sacrum, as if one had been lying on too hard a
couch.
362
A TEXT-BOOK OF GYNECOLOGY.
Kreosotum.-Drawing pain along the coccyx down to the rec-
tum and vagina, where a spasmodic contractive pain is felt;
better when rising from her feet.
Consult:-Cimicifuga, ferrum phos., zincum, thuja, muriatic
acid, rhus tox., kali carb., and ruta grav.
CHAPTER XXV.
CONGENITAL AND ACQUIRED MALFORMATIONS
AND DISEASES OF THE VAGINA.
OCCLUSIONS.
The various conditions which give rise to occlusions of the
vagina are:-
Atresia vulvæ,
Imperforate hymen,
Persistent hymen,
Congenital atresia vaginæ,
Acquired atresia vaginæ.
Symptoms.-Atresia vulvæ is usually discovered during in-
fancy; the other form of occlusions are ordinarily not detected
until they interfere either with the exit of the menstrual blood
or the marital relations.
The occlusion, whatever the cause, may be either partial or
absolute. When the menstrual blood is retained the subjective
symptoms are the same as have been described under the head of
"Retention of the Flow."* The girl reaches an age when she
should menstruate and undergoes all the physical changes of
puberty. At certain regular intervals all of the phenomena of
menstruation recur-except the flow. There is an exaggerated
degree of suffering, and the pain is of a bearing-down character.
Sooner or later the retained discharge gives rise to a tumor.
A physical exploration is always necessary in order to determine
the cause of the obstruction. The same symptoms occur when
the obstruction is higher up in the uterus.
Results of Menstrual Retention from Occlusions of the
Genital Tract.-The higher the occlusion is located in the geni-
tal canal the greater is the danger of rupture from distention of
*
v. page 233.
363
364
A TEXT-BOOK OF GYNECOLOGY.
the uterus and Fallopian tubes. If the obstruction is located at the
hymen, or low down in the vagina, the distensibility of the
canal will enable it to expand greatly before the uterus becomes
dangerously distended. It is claimed by some prominent
authorities that hematosalpinx never results from a reflux of
blood through the uterine ends of the tubes, even though the
uterus is enormously distended. The Fallopian distention, it is
maintained, is due to a vicarious discharge from the lining mem-
branes of the tubes, which is excited by the obstruction. However
this may be, hematosalpinx is oftener found in occlusions of the
cervix than in occlusions of the vagina, and tubal rupture, with
resulting peritonitis, is liable to occur at any time; or if the
uterus be suddenly emptied uterine contractions are occasionally
excited which may extend to the tubes and cause rupture.
Again, as a consequence of the distention, wherever the tumor
may be located, the uterus and Fallopian tubes are carried high
up in the pelvis, and the latter often become adhered. As a
result they are dragged upon after the uterus descends, and in
this way rupture may occur.
ATRESIA OF THE VULVA.
Atresia of the vulva may be either congenital or acquired.
When congenital it is usually detected soon after birth by the
nurse, who, in bathing the child, observes that something is
wrong. It rarely involves the urethral orifice, so that urination
is not interfered with. Should the agglutination seal entirely
the opposing lips of the vulva retention of the urine would, of
course, result. When acquired, it is usually due to vulvitis with
resulting adhesions.
The firmness of the adhesion varies greatly, though it is
seldom difficult to overcome The diagnosis is easily made by
separating the labia, and the treatment is, ordinarily, most simple.
If the agglutination extend high up, and has become firm, a
dissection more or less extensive may be necessary.
I have,
however, never met with such a case, though I have repeatedly
had to do with this form of atresia in babies and young children.
In almost all instances adhesions of the clitoris are associated
with the condition and should be broken up at the same time.
MALFORMATIONS AND DISEASES OF THE VAGINA.
365
Any blunt instrument or probe will serve the desired purpose.
This is passed between the labia in such a way as to separate
them perfectly. Care should be taken to prevent re-agglutination
by keeping the raw surface separated for a few days with a strip
of lint smeared with carbolized vaselin.
Notwithstanding the ease with which the diagnosis can be
made and the obstruction overcome, I have had patients brought
to me from a distance of two hundred miles because the medical
attendant believed that he had to do with an extensive and a firm
atresia.
IMPERFORATE HYMEN.
Anatomy. The hymen (Fig. 1, h) separates the external and
internal organs of generation. It is supposed to be formed by
the closed lower ends of Müller's ducts. In shape it is usually
crescentic; the opening may be circular, cribriform, or there
may be two large openings separated by a narrow strip of mem-
brane. It is occasionally absent, even in virgins, and in parous
women the caruncula myrtiformes are usually the only remaining
evidences of the organ.
The presence of the hymen is not absolute proof of virginity;
nor does its absence prove that sexual intercourse has taken place.
It is possible for sexual congress to occur without its rupture, and,
as we have seen, it may be congenitally absent. Its rupture is fre-
quently the result of other causes than sexual congress—injury,
examinations, onanism, etc. From a medico-legal standpoint this
fact is important, and the practitioner cannot be too cautious
in presenting testimony bearing upon the question of virginity.
There are many cases on record in which pregnancy occurred
before the hymen was ruptured.
Symptoms. In by far the larger proportion of cases the
obstruction gives rise to no trouble previously to puberty. In-
deed, the patient may not seek relief until marriage, for,
strangely enough, the system will occasionally adapt itself to the
unnatural condition; and, after a period of suffering more or less
prolonged, a fair degree of health is enjoyed. Usually, how-
ever, the symptoms resulting from the retained menstrual dis-
charges call for immediate relief. During the molimina there
is more or less fever, nausea, vomiting, headache, etc. The
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A TEXT-BOOK OF GYNECOLOGY.
pelvic pain is very great, and radiates down the thighs. The
rectum and bladder are often impinged upon and their func-
tions interfered with. As the case progresses, the complexion
becomes sallow, the headache constant, and there may be mani-
festations of septicemia and pyemia, as indicated by chills,
increased temperature, etc. Sometimes vicarious bleeding takes
place from the nose, lungs, rectum, or from any part of the
body.
Physical Examination.-Rarely do all of the foregoing
symptoms occur in a given case, yet a persistence of any num-
ber of them, especially if they exacerbate at more or less regular
intervals, calls for a physical examination. This will reveal a
tumor of greater or less size, depending upon the duration of the
occlusion and the capacity of the pelvis. There is a bulging of
the hymen, and the finger carried into the rectum will detect
the presence of a fluid tumor crowded against it. By recto-
abdominal palpation, fluctuation can at times be detected.
The distention is greatest immediately after the subsidence of
the molimina. There is undoubtedly more or less resorption
during the intermenstrual period, and, as has already been sug-
gested, if menstruation ceases because of the anomalous condi-
tion, the accumulated blood may be largely resorbed. The
given history, supplemented by a careful physical exploration,
will usually enable the practitioner to make a correct diagnosis.
Notwithstanding the fact that the operative measures neces-
sary to overcome the obstruction are very simple, a guarded prog-
nosis should be given. All specialists are agreed as to this.
Retained menstrual blood, from whatever cause, cannot be liber-
ated with impunity. The greater the quantity and the longer it
has been retained the more dangerous is its withdrawal. I have
previously mentioned some of the accidents to be dreaded—
reflux of blood through the Fallopian tubes into the abdomen,
and rupture of the tubes. A still more serious one is that of
decomposition through the admission of air.
Treatment.-Operators are not agreed as to the best method
of removing the pent-up discharge when due to the cause under
consideration. Emmet and a few followers advocate a large in-
cision, rapid evacuation, and subsequent douching of the cavity
•
MALFORMATIONS AND DISEASES OF THE VAGINA.
367
until the water returns clear. The larger number of operators,
however, prefer the more conservative method of gradual evac-
uation. It is claimed by the advocates of the latter method
that there is much more danger of blood poisoning and rupture
of the uterus and the tubes when the fluid is rapidly withdrawn.
Recent statistics bearing upon the subject tend to uphold this
claim. Thus Hemenway* has collected 81 reported cases of
imperforate hymen, which were operated upon with the following
result: Of the 56 cases rapidly evacuated the mortality was 7,
or 12.5 per cent.; whereas of the 25 cases operated upon by the
gradual method but one died, a mortality of but 4 per cent.
An
analysis of Emmet's cases † shows that the quantity of blood
evacuated in each was not great,—an average of about six ounces.
This is a very different state of affairs from that represented in
Fig. 65. In this representation the uterus is carried upward, its
cavity and that of the vagina are greatly distended, and their
absorbing surfaces much increased. Even if sepsis could be
avoided in cases of this kind by the strict observance of every
precaution the danger of laceration and rupture from the drag-
ging upon the parts would, in rapid evacuation, be very great.
Ross, ‡ in order to prevent collapse in these cases, makes a small
opening into the hymen, through which he passes the douche
nozzle and washes the treacly discharge entirely away. The cav-
ity is kept distended with fluid until it is forced out by iodoform
gauze, which is carefully packed into it. The gauze, he main-
tains, is soft, unirritating, and antiseptic, affording both support
and drainage. If rapid evacuation be practised in the larger
accumulations this procedure appeals to my judgment. At any
rate, in the light of the statistics now available, and with modern
antiseptic methods, it is probable that the smaller accumulation
can be rapidly evacuated with but little danger. The cavity
should be washed out with a 1:5000 bichlorid solution, being
careful that it is properly drained. This should be repeated often
enough to prevent resorption of any of the discharge.
* American Journal of Obstetrics, Nov., 1891.
+"Principles and Practice of Gynecology," p. 195, 1884.
Journal of the Am. Med. Association, 1891.

368
A TEXT-BOOK OF GYNECOLOGY.
In the larger accumulations, on the other hand, and particu-
larly if the Fallopian tubes are distended, gradual evacuation
would seem to be the safer procedure. In it care must be taken
to prevent the invasion of germs. A small quantity of fluid may
be daily drawn off by means of an aspirator; or a small, elliptic
incision may be made in the hymen in such a way as to prevent
rapid egress of the fluid (Hewitt). A still safer and better method
FIG. 65.
C."EVY
C.BOOLDANZ
IMPERFORATE HYMEN WITH DISTENTION OF VAGINA AND UTERUS.
is, to my mind, the following: About three feet of rubber tubing
is attached to a medium-sized trocar. This is filled with a five
per cent. carbolic solution, the lower end of the tube being kept
immersed in the same solution. After the genitals have been
thoroughly scrubbed in bichlorid the point of the trocar is passed
into the hematic tumor and the accumulation permitted grad-
ually to drain away. This will require some days, during which
time the patient should lie quietly in bed. After the trocar is
MALFORMATIONS AND DISEASES OF THE VAGINA.
369
removed the opening made by it is to be kept patulous by the
insertion of a drainage tube, through which the cavity can be kept
clean by frequent washings. By this method the danger from
both sepsis and rupture is reduced to a minimum. Should,
however, the evidences of sepsis supervene there is but one
course to pursue, and that is to open the hymen freely and to
remove, under a bichlorid stream, as much of the débris as can
be removed.
A subsequent operation is usually necessary, after any of the
gradual methods, for the purpose of destroying the hymen.
This may be done by entirely removing the membrane with a
pair of curved scissors, and closing the wound thus made with
a continuous catgut suture; or by making three or four incisions
down to its base and inserting a Sims vaginal dilator, which is
to be retained for several days. I much prefer the former
method because it does away with all remnants of the hymen,
which, if left behind, sometimes become inflamed and give rise
to vaginismus.
PERSISTENT HYMEN.
In this condition there are one or more openings in the hymen
which insure the egress of the menstrual blood. The membrane
is, however, unduly tough, and prevents or interferes with the
intromission of the male organ.
It is usually not discovered until an attempt at coition has
been made. Indeed, the first knowledge of the unnatural con-
dition is often obtained by the accoucheur, who finds the hymen
stretched over the advancing head. In these cases conception
has occurred notwithstanding partial intromission, the semen
having found its way through the hymeneal aperture or aper-
tures; or the hymen, after frequent attempts at intercourse, be-
comes stretched and elongated to such a degree as to permit the
complete insertion of the male organ. It is a well-known fact
that conception may occur through a very minute opening.
If not interfered with, the membrane may be ruptured during
the parturient act, but if very dense it can oppose great resist-
ance, and there is danger of serious injury being done to the
vaginal outlet.
24
370
A TEXT-BOOK OF GYNECOLOGY.
A perfectly normal hymen may remain intact because of
the inability of the male to rupture it. In time, if sexual inter-
course is persisted in, the parts become tender and sore, which
leads the patient to consult her medical attendant. Instances are
on record in which the urethra has been greatly dilated by the
introduction of the male organ, the unyielding hymen directing
it into the urinary canal.
The treatment, under whatever circumstances the anomaly is
discovered, is very simple. The hymen is to be removed in the
manner already described under the preceding head. Spon-
taneous rupture should never be permitted in parturition. It is
much safer to overcome the obstacle by stellate incisions made
with a pair of scissors. The raw surfaces are to be kept from
reuniting by a pledget of iodoform gauze.
CONGENITAL AND ACQUIRED ATRESIA VAGINE.
Congenital atresia of the vagina presents itself under several
different forms. The Müllerian ducts may have so failed in their
development as to produce no trace of the canal; or they may
have created the lower part of the canal, the upper being en-
tirely closed; or there may be two cul-de-sacs, one above and
the other below a central partition; or the canal may be repre-
sented simply by a fibrous cord.
Acquired atresia likewise varies greatly in form and extent.
It may result from any one of a number of causes, though pro-
longed pressure of the fetal head is oftener responsible for it
than anything else. However, any disease or accident giving
rise to inflammation, ulceration, or sloughing may end either in
atresia or stenosis. Such are: vaginitis, syphilitic ulceration, or
ulceration resulting from low fevers, the application of strong
medicaments, and traumatism.
Symptoms. Like imperforate hymen, atresia in itself gives
rise to no inconvenience, and it is only when the disorder ob-
structs the menstrual discharge, or interferes with coition, that
trouble is caused. When congenital, therefore, it is rarely de-
tected until puberty, and often not until marriage. If the uterus
and ovaries are developed, there will be retention of the men-
MALFORMATIONS AND DISEASES OF THE VAGINA.
371
•
strual discharge, with all of the symptoms incident to that condi-
tion. On the other hand, if the development of these organs has
also been arrested, the function of menstruation is held in abey-
ance, and the amenorrhea is absolute. In the latter event all
signs of puberty are wanting: the breasts do not develop, no hair
appears upon the mons Veneris, and the figure assumes few of
the characteristics of womanhood.
If the atresia be acquired, and is the result of parturition, the
patient, having already menstruated, will suffer from menstrual
retention when ovulation is reëstablished.
Physical exploration will, in most instances, enable the ex-
aminer to determine the nature of the trouble. It is not,
however, always so easy to determine the presence or absence
of the uterus and ovaries. If all signs of the molimina are
wanting, together with the usual changes of puberty, the physi-
cian is reasonably safe in concluding that they are either absent
or arrested in their development. The examination should be
conducted as follows: Place the patient upon her back and
practise recto-abdominal palpation, endeavoring to press the
organs toward the finger in the rectum. Under anesthesia this
is sometimes very satisfactory. Next pass a sound into the
bladder, and direct its tip toward the finger in the rectum. If it
come in contact with the finger, the evidence is pretty conclusive
that no uterus intervenes. By carrying the point of the sound
toward the lower part of the rectum the examiner can deter-
mine the thickness of the structures between the bladder and
that organ. This is important in determining whether or not an
operation is practicable.
Prognosis. There are many factors to be considered in deal-
ing with the prognosis of vaginal atresia. It may be stated in a
general way that the prospects of restoring the canal to its former
condition, or, by surgical interference, of making a new vagina,
depend upon the amount of tissue intervening between the
bladder and the rectum. In the congenital cases, if there is no
vestige of the canal, and if the uterus is absent, the possibilities
of creating a new vagina are not encouraging. On the other
hand, if the vagina is represented by a fibrinous band leading
to the uterus, or if the closure is the result of accident, without
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A TEXT-BOOK OF GYNECOLOGY.
the loss of too much tissue by sloughing, the prognosis is much
more favorable.
Too much, however, must not be promised. I know of noth-
ing more trying to either the surgeon or the patient than an
attempt to create a new vagina. There are few women willing
to endure the long suffering incident to such a procedure. Yet,
with the coöperation of the patient, it is surprising what can be
done even in the worst cases. When the operation is performed
chiefly for the purpose of liberating pent-up menstrual discharge
it may not be wise to attempt to create a canal of normal size.
If, however, there be sufficient tissue to permit of this without
endangering the rectum and bladder, it should be made.
Treatment.—The question of operative interference in a given
case of atresia must depend upon circumstances. The occlusion
in itself, like imperforate hymen, neither endangers life nor
gives rise to great inconvenience. It is only when it interferes
with one or both of the functions mentioned-menstruation and
coition—that we are called upon to decide as to the necessity
of an operation.
There is no question as to the wisdom of operative interfer-
ence if the menstrual blood is retained, and there is a fair pros-
pect of reaching it. On the other hand, if the patient has never
shown any signs of menstruation, probably because of an absence
of the uterus and ovaries, the sole object of the operation is to
make sexual congress possible; here the decision must rest
with the patient. I question very much the right of a woman
thus afflicted to assume the responsibilities of the married state
if aware of her condition previously to entering upon it. Unfor-
tunately, these patients are usually ignorant of their deformity
until an attempt is made to consummate the marriage, and it is
their inability to consummate it that brings them to the specialist.
In all instances of the kind we are justified, if it is the patient's
wish, in making an attempt to create a vagina, as we are also
where the atresia is acquired, providing there be a fair prospect
of success.
The operation, though not complicated, nevertheless requires
care, perseverance, and skill. The patient should be thoroughly
anesthetized and placed in the lithotomy posture, with the hips
MALFORMATIONS AND DISEASES OF THE VAGINA.
373
well over the edge of the table. The anatomical relationship is
ascertained as accurately as possible by keeping the index finger
of the left hand in the rectum, and the sound, held by an assist-
ant, in the bladder. A transverse incision through the skin and
cellular tissue is made in front of the anus. It is always wise
to work as close to the rectum as possible, because, with the
index finger in this organ to serve as a guide, there is much less
danger of penetrating it than there is of penetrating the blad-
der.
After the skin is incised the cutting instrument should be used
as little as possible; it is much less dangerous to bore one's way
into the tissues with the finger, aided, if necessary, by the handle
of a scalpel. If space will permit, the caliber of the canal should
be greater than normal because of the tendency of the tissues to
contract during the healing process. Such a dissection as this
is long and tedious, and it may be necessary to complete it,
because of the exhaustion of the patient, at a subsequent opera-
tion.
The question of penetrating the uterus, if the cervix is found
closed, will also depend upon the condition of the patient. If the
shock is already great, because of the duration of the operation,
it is best not to open the uterus until some future time.
After the canal has been made or reopened it is to be kept
patulous by the Sims dilator, or by a strip of iodoform gauze
packed into it. I prefer the latter method, changing the dressing
for the first time at the end of forty-eight hours, and, subse-
quently, every twenty-four hours. Later on the Sims dilator
can be advantageously used. In time epithelium forms over the
raw surface, and it is surprising how very like normal vaginal
mucous membrane the interior of a vagina thus made becomes.
The parts must be kept patulous for months by artificial
measures, and it is this procedure which greatly taxes the en-
durance of the patient. She should be instructed how to insert
the Sims dilator, which, if too painful to be worn continuously,
should be left in for an hour twice a day. Specular dilatation
from time to time may be necessary.
Puncture through the rectum or above the pubes, for the pur-
pose of reaching the retained discharge, is hardly a justifiable
374
A TEXT-BOOK OF GYNECOLOGY.
operation except in extreme cases. I dislike always to drain
any cavity into the rectum if such a procedure can possibly be
avoided. Fecal contamination is almost inevitable and the prin-
ciple of drainage is wrong. Nevertheless, if the tumor bulges
into the rectum, and the tissues corresponding to the vaginal
tract are limited, this may be the only resource.
DOUBLE VAGINA.
Double vagina is occasionally met with as one of the anoma-
lies of development. In most instances it is associated with a
double uterus, though not always. The septum dividing the
two vaginæ may be complete or partial, and consists of a double
layer of mucous membrane, separated by more or less muscular
tissue. Where the septum is incomplete it may be found stretched
across the upper, middle, or lower portion of the vagina. Some-
times it is perforated.
The two sides of a double vagina are usually of unequal
size, one being much smaller than the other. This is always
the case when the double canal leads up to a one-horned uterus,
the side corresponding to the absent cornu remaining rudimen-
tary. On the other hand, when the uterus is double, both sides
may be fully developed. Each half is generally guarded by a
hymen.
DOUBLE HYMEN.
This rare condition has been met with in different forms. The
two hymen may be placed one immediately above the other, or
the upper one may be high up, close to the cervix. The latter
condition sometimes is very confusing, as was the following case:
Mrs. æt. 28, was referred to me by Prof. Walter Wesselhoft
of Boston. As a girl she was strong and vigorous, never having
suffered from dysmenorrhea; after marriage, soon after which she
became pregnant, there was not the slightest history of dyspa-
reunia. Pregnancy progressed in a perfectly normal way, and at
the end of gestation Dr. Wesselhoeft was called upon to care for
her in labor. To his surprise he found at the upper part of the
vagina a septum, through which he could not pass the finger. If
MALFORMATIONS AND DISEASES OF THE VAGINA.
375
an opening existed, which must have been the case to have per-
mitted of conception, it could not be detected by the examining
finger. The septum was cut through and the labor terminated
by forceps. The patient made a good recovery, and in due time
came to Michigan to reside, when she placed herself under my
care. I made an examination twelve months after delivery. The
upper part of the vagina was narrowed and the septum referred
to was perforated by an opening about one-quarter of an inch
in diameter. The edges of it were thick and indurated and the
cervix impinged upon its upper border. The cervix was badly
lacerated, everted, and eroded, which condition, together with
the obstacles interposed by the septum, led me to think, on
making the first examination, that there was a double uterus.
A second examination, however, convinced me that this was not
the case.
The uterine catarrh was perpetuated by the retained
secretions above the septum, and the patient suffered more or
less in a general way as a result of this. The preliminary treat-
ment consisted of frequent douches and the application of the
compound tincture of iodin twice a week; after these applica-
tions a strip of iodoform gauze was packed about the cervix
above the septum. The gauze afforded good drainage and the
improvement was rapid. My intention was entirely to remove the
septum and to repair the cervix in the usual way. When I came
to operate I found, to my surprise, that the septum was composed
of a duplicature of the vagina, folded upon itself in such a way
that the bladder and the Douglas cul-de-sac were turned into it.
My first incision opened into the peritoneal cavity through the
cul-de-sac, so that, after carefully closing it, I desisted from further
efforts to remove the septum. I enlarged the opening by nicking
it, and with much difficulty succeeded in repairing the cervix.
The patient made an uneventful recovery and is now quite well.
VAGINAL CYSTS.
These sometimes form in the vagina and vary in size from a
walnut to an orange. They may result from the persistence of
Gartner's ducts, or from occlusion of some of the muciparous
follicles. In the first instance they are found on the anterior
376
A TEXT-BOOK OF GYNECOLOGY.
vaginal wall at its lower part; if formed by the distention of
muciparous follicles they are located in the fornices of the
vagina. They contain a limpid fluid which sometimes
becomes viscid. When located on the anterior vaginal wall
care must be taken not to confound them with cystocele. The
introduction of a catheter will enable the physician to differen-
tiate the two conditions. The treatment is very simple: they
should be cut into, evacuated, and packed with gauze previously
dipped in a solution of iodin.
HERMAPHRODISM.*
This term is applied to that congenital condition of the sexual
organs in which the ovaries and testicles exist in the same indi-
vidual. True hermaphrodism is extremely rare, yet undoubted
cases of it have been recorded. That of Katharine Hohmann is
a well-known instance.†
Both ovaries and testicles, or but one of each, may exist in
the same person. This constitutes true hermaphrodism, and,
as I have already said, is an extremely rare condition. Pseudo-
or false hermaphrodism is, on the other hand, much more com-
mon. Here, owing to malformation, the external genitals re-
semble more or less closely the sexual organs of the opposite
sex. Thus hypospadiasis in the male may so divide the
sexual organs as to make them resemble the vulvar cleft in the
female; or the clitoris in the female may be so enlarged as to
resemble the penis, while the labia minora, because of their close
proximity, are mistaken for the scrotum. If the individual be a
male, the testicles will, in most instances, be found in the struc-
tures simulating the labia and scrotum. It must, however, be
borne in mind that the testicles may not have descended; and
that the ovaries may find their way into the pudendal sac.
These confusing factors may make it impossible to determine
the sex until the age of puberty is reached. The menstrual
*" Hermaphroditus was fabled to be the son of Hermes (or Mercury) and Aphrodite
(or Venus), and to have united both sexes in one person."—Joseph Thomas.
+ Thomas and Mundé, p. 119, 1891.
MALFORMATIONS AND DISEASES OF THE VAGINA.
377
function will then assert itself if the patient be a female, and the
breasts, the face, the form, the voice, etc., will serve as distin-
guishing features. Sometimes the uterus and ovaries can be
palpated through the rectum. When called upon to determine
the sex of an infant too much care, for obvious reasons, cannot be
exercised.
CHAPTER XXVI.
VAGINITIS.
The mucous membrane of the vagina is perhaps oftener
attacked by inflammation than any other mucous membrane of
the body. When thus affected it is known as vaginitis, colpitis,
blenorrhagia, or blenorrhea. These several terms are used syn-
onymously by different writers to indicate the various forms of
inflammation attacking this organ.
Anatomy. The peculiar structure of the vagina is one of the
reasons why it is so frequently the seat of inflammation. It
extends from the ostium vagina to the cervix uteri and con-
sists of three coats-fibrous, muscular, and mucous. The
fibrous and muscular coats are attached to the ischio-pubic rami,
constituting a part of the perineal septum. The mucous mem-
brane is lined with squamous epithelium. The posterior wall
is about four inches long, being twice the length of the anterior.
This throws the anterior wall into transverse ruga, which greatly
increase its mucous surface and form nidi for the reception of
virus (Fig. 10).
Neumann doubts the existence of true muciparous follicles in
the vagina.* Von Preuschen maintains that they do exist, but
that they are limited to the upper portion of the vagina. There
is, however, no question regarding the existence of numerous
papilla which cover the folds or rugæ.
Varieties.-Vaginitis may be divided into four forms: 1.
Simple; 2. Specific or gonorrheal; 3. Granular or papillary;
and 4. Senile or adhesive.
SIMPLE AND SPECIFIC VAGINITIS.
While I believe that these two forms result from entirely
different causes-the specific always being due to gonorrheal
* Deutsche medicinische Wochenschrift, 1890.
378
VAGINITIS.
379
infection—yet clinically it is often impossible to differentiate
them. I therefore deem it more practicable first to study their
clinical manifestations conjointly, referring in conclusion to the
differential points given by various authors.
The causes may be enumerated as follows:-
I. Contact with specific poison;
2. Contact with various irritating and mechanical agents used
for disinfecting or examining purposes;
3. Contact with discharges from the uterus or from abscesses
opening into the vagina;
4. Undue exposure;
5. Excessive coitus;
6. Disordered blood states resulting from phthisis, the exan-
themata, etc.
7. Traumatism due to parturition, the use of pessaries, etc.
Simple and specific vaginitis may be either acute or chronic
and, as the list of causes shows, occur not infrequently as
secondary affections. The simple is much oftener secondary.
than the specific, resulting from extension of inflammation of
contiguous structures, or from contact with discharges issuing
from the uterus or pelvis. Undoubtedly the condition of the
system has much to do with the acuity of the symptoms. A
simple chronic vaginitis may have existed for an indefinite
period in one otherwise perfectly well, when, if for any reason
the patient's vitality is reduced to a certain point, it will assume
the form of an acute inflammation upon the slightest provoca-
tion. The acute form, unless arrested by proper treatment,
rapidly passes into the chronic.
Pathology.—The characteristic changes attending inflam-
mation of any of the mucous surfaces, modified only by the
anatomical structure of the parts involved, take place in vagini-
tis. The parts are at first dry, hot, and congested. This con-
gestion is, in due time, relieved by an exudation, which is at first
serous but, in a few days, becomes purulent. The duration of
the first stage is variable-from a few hours to several days.
The extent of tissue involved depends both upon the cause and
the vitality of the patient. Thus the involvement is usually
greater and more serious in the specific than in non-specific in-
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A TEXT-BOOK OF GYNECOLOGY.
flammation; and the sub-mucous structures are more apt to be
implicated when the affection occurs as a complication of the
exanthemata, or puerperal fever. A true phlegmonous process
may be inaugurated by the involvement of the deeper structures.
Not infrequently the epithelium is shed in patches, leaving the
underlying surfaces exposed; or occasionally the entire epithe-
lial layer of the vagina is cast off en masse, owing to the intensity
of the disease. The inflammation may extend over the entire
mucous area of the vagina, as well as that of the vulva and
urethra, or be limited to the vaginal fornices.
Symptoms. The intensity of the symptoms depends in large
measure upon their acuity. The onset of an acute attack is
usually characterized by a slight chill or chilliness. This is soon
followed by a sensation of heat or burning in the region of the
vagina or vulva, which is often very intense. There is heaviness
and frequently an aching sensation in the pelvic region, which
extends down the thighs or radiates upward. Sooner or later
a more or less profuse discharge occurs, which is often exceed-
ingly excoriating and gives rise to intense pruritus. Dysuria,
from involvement of the urethra, is a frequent complication, and
when the cause is gonorrheal infection it may be most dis-
tressing and obstinate.
The local symptoms become less marked as the disease assumes
a chronic form, until finally they disappear entirely. The dis-
charge may, however, continue in the form of a leucorrhea for
an indefinite length of time after the local suffering ceases.
Physical exploration will reveal one or all of the changes men-
tioned under the head of pathology. If the examination be
made during the first stage of the disease the parts will be found
hot, dry, and tender. Later on they are bathed in a profuse
secretion of purulent matter, which escapes upon separating the
labia. By drawing the finger along the tract of the urethra pus
is often forced from it.* A specular examination will usually
* In this connection the observations of Horand are valuable (L'Union Médical,
Aug., 1889). Of 483 women examined there was a urethral discharge in 143.
Horand, while believing that it was frequently due to gonorrhea, maintains that such
discharge often results from a simple folliculitis. This discharge is occasionally seen
in virgins with absolutely no signs of inflammatory involvement of either the urethra
or the vagina.
VAGINITIS.
381
reveal abraded patches, or, possibly, the evidences of true
ulceration. Involvement of the cervix is also frequently ob-
served. During the acute stage a specular examination,
because of the pain produced, is hardly justifiable. Later on
this instrument is useful in differentiating endometritis and
pelvic abscess from vaginitis. Pelvic abscess opening into the
vagina has more than once been mistaken for the latter condition.
These cases, because of the fact that vaginitis is frequently ex-
cited by the discharge from the abscess, are often misleading.
Differentiation Between Simple and Specific Vaginitis.—
This question has already been discussed in Chapter IV, to which
the reader is referred. It must be admitted that few investiga-
tors are as sanguine as Aubert, whose opinion is there given, in
relying upon the gonococcus of Neisser as furnishing conclu-
sive evidence of the specific nature of vaginitis. Thus, Vibert
and Bordas * affirm that gonococci are practically indistinguish-
able by any means yet known to us from other forms of micro-
organisms, and that there is no other way by which, in medico-
legal cases, the two forms of inflammation can be distinguished
the one from the other. Currier † believes that specific vaginitis
is always caused by the gonococcus of Neisser, but admits that
it is not always present in gonorrheal pus; Ollivier asserts it as
his belief that in the present state of knowledge we cannot
absolutely demonstrate the infectious principle of gonorrhea;
and, finally, Thomas and Mundé, in their latest work affirm
that differentiation between the acute and subacute forms of the
two affections can seldom, if ever, be made.
L
All of the authorities quoted are quite agreed that the cause
of specific vaginitis is always a specific discharge, though nearly
if not quite all admit that non-specific vaginitis occasionally
gives rise to urethritis in the male. There certainly exists
much confusion regarding the subject, and the medico-legal
expert should give his testimony with much caution. In cases
of rape, for instance, or where the chastity of a girl or woman is
at stake, the responsibility of the medical expert is very great.
* Le médecine moderne, Paris, 1890.
† Medical News, 1889.
Op. cit.
382
A TEXT-BOOK OF GYNECOLOGY.
It is no small thing to ruin the reputation of either a man or
woman by evidence based upon a pathology as yet unsettled.
There are, however, symptoms other than those obtained by
microscopical examination of the pus which will at least lead
the physician to suspect the form of vaginitis met with. Of first
importance is the infectious character of the discharge. There is
no question but that specific vaginitis is infinitely more liable to
excite urethritis in the male than is the simple form. In proof of
this, it is only necessary to remind the reader of the frequency
of vaginal catarrh in married women, and the comparatively few
cases of urethritis in the male resulting from the same; whereas,
a single cohabitation with a prostitute will, in at least a goodly
per cent. of cases, give rise to virulent urethritis.
The acuity and intensity of the symptoms will lead us to
suspect the specific nature, though simple vaginitis not in-
frequently runs a course quite as acute and virulent as the
specific form.
Urethral complications occur oftener, as has been shown, in the
specific form of the disease. Indeed, the inflammation may, in
gonorrhea, be confined almost entirely to the urethra.
Other circumstances should be noted. For instance, if the
foregoing symptoms suddenly develop in a woman who has
never before suffered from vaginal discharge, we are at least
warranted in suspecting gonorrhea. On the other hand, if a
girl preserves all of the evidences of virginity, as shown by the
hymen, etc., and if her reputation is such as to make illegitimate
intercourse improbable, we ought at least to give her the benefit
of the doubt, and consider the case one of simple vaginitis.
(C
Course and Termination.-Gonorrhea is supposed to be a
self-limited disease. Until 1873, in which year Noeggerath wrote
a most startling paper on the subject, its remote effects in the
female were considered most insignificant. In the paper referred
to Noeggerath makes the following affirmation :
. I
believe that I do not go too far when I assert that of every one
hundred wives who marry husbands who have previously had
gonorrhea, scarcely ten remain healthy; the rest suffer from it,
or some other of the diseases which it is the task of this paper to
describe. And of the ten that are spared, we can positively
VAGINITIS.
383
affirm that in some of them, through some accidental cause, the
hidden mischief will sooner or later develop itself."
There can be no doubt that gonorrhea is frequently respon-
sible for perimetric inflammation and pyosalpinx. I have more
than once been able to trace the mischief to this source, and
while engaged in writing this chapter I had occasion to operate
for Dr. E. F. Chase, of Dexter, Mich., on a patient who presented
the following history: Though married, she was but seventeen
years old, and not well developed for one of her years. Pre-
viously to marriage Dr. Chase had treated the husband for
gonorrhea, and all discharge had ceased. Soon after marriage,
however, the patient was taken with severe inflammatory symp-
toms, accompanied with agonizing pain in the pelvic region.
Her symptoms grew from bad to worse, the temperature running
up very high and presenting all the characteristics of pyemia;
the pulse became more and more rapid, and her general appear-
ance clearly indicated a fatal termination if the progress of the
disease were not arrested.
An examination under chloroform revealed the usual board-
like hardness of the pelvic roof. I opened the abdomen two
days after making the first examination (about six weeks from
the onset of the first symptoms) and dug the distended tubes
and the friable ovaries from a mass of inflammatory exudates.
Many intestinal adhesions were separated, the abdomen washed
with sterilized water, a drainage tube inserted, and the wound
closed. The patient nearly died from shock while on the table,
the operation requiring fifty minutes, but rallied, only to suc-
cumb fifteen hours later.
Cases like the above, I am sorry to say, are only too common.
There was no history of traumatism or of other possible cause
of the mischief. The symptoms came on insidiously and were
preceded by a vaginal discharge.
Noeggerath is probably right in maintaining that gonorrhea
may remain latent in both the male and female for almost an
indefinite length of time. Lawson Tait, in support of the teach-
ings of Noeggerath, contends that gonorrhea is responsible for
infinitely more suffering, and is infinitely more serious in its con-
sequences, than is syphilis. More recently, however, there is a
384
A TEXT-BOOK OF GYNECOLOGY.
tendency to question the sweeping assertion of Noeggerath
and Tait as to the almost inevitable transmission of the disease
from the male to the female. Gonorrhea in the male is, unfor-
unately, too common to justify it. Bantock, of London, who has
certainly had extraordinary opportunities for observation, informs
me that, in England at least, Noegerrath's statement does not
hold good.
While admitting, then, that specific vaginitis frequently does
give rise to serious and often fatal pelvic complications, it is prob-
able that both forms of the inflammation may run their course
without extending above the vagina.
GRANULAR OR PAPILLARY VAGINITIS.
Definition. These terms have been applied to a form of in-
flammation attacking the vagina characterized by a hypertrophy
of the vaginal papillæ. For a long time it was supposed to be
a hypertrophy of the muciparous follicles, but, if the teachings
of Neumann are correct, these follicles, if they exist at all in the
vagina, are very limited. The papillæ, on the other hand, are
found scattered over the transverse folds in large numbers, and,
in all probability, the granular appearance which characterizes
the disease is due to their enlargement.
There is a certain resemblance between granular vaginitis and
follicular vulvitis. Both are much oftener met with during
pregnancy, and both commonly continue until utero-gestation is
terminated. A follicular vulvitis frequently implicates the vagina,
and, conversely, I have seen granular vaginitis ending in the
former condition. The physiological congestion of pregnancy
tends to produce both diseases.
It is by no means peculiar to the pregnant state. One of the
worst cases that I ever met with occurred in a virgin twenty-six
years of age. The impression obtained on digital examination
was not unlike that experienced on scraping the finger over the
surface of a beef's.tongue.
Symptoms. The symptoms do not differ essentially from
those of the two forms of vaginitis already studied. In the cases
coming under my observation the acute manifestations were not
so marked, but the irritation and pruritus were infinitely greater.
VAGINITIS.
385
The enlarged papillæ can be plainly seen and felt. They extend
from the ostium vaginæ to the cervix, and sometimes stud the
entire surface of the latter.
TREATMENT OF VAGINITIS.
The treatment of the three forms of vaginitis which have been
considered is so much the same as to make a separate con-
sideration of each unnecessary. During the acute stage quiet
must be observed, the patient being confined to her bed for two
or three days. Aconite, belladonna, and cantharis are the reme-
dies oftener useful in controlling the pain and the slight fever
present. A bichlorid douche (1:3000) should be used every
five or six hours. Instead of the bichlorid the fluid extract of
hydrastis canadensis is recommended by Cowperthwaite.* The
injections, whatever medicament is used in the water, must be
thoroughly made according to the method described in chapter
X. Later on, when the discharge assumes a purulent char-
acter, a solution of calendula and glycerin can be advantageously
used after the parts have been washed with the bichlorid solu-
tion.
When the acute symptoms have subsided the douches need
not be administered oftener than twice a day. I then apply the
nitrate of silver after the method described by Skene. The
parts are exposed by the aid of a Sims speculum and a one-grain
solution of the silver is sprayed with a good atomizer over the
whole vaginal surface. The force of the atomizer causes the
fluid to come in contact with the vaginal folds much more
thoroughly than is possible by simple applications and makes
the stronger solutions unnecessary. This treatment is repeated
once a day until the pain is relieved, after which the so-called
dry treatment" is to be substituted for it. This consists of
various preparations of powder sprinkled upon a dry tampon,
which is inserted in such a way as to keep the opposing vaginal
walls separated. For this purpose I prefer iodoform and bismuth,
equal parts. The tampons should not be worn longer than
twenty-four hours, when they are to be removed, the vagina
* "A Text-book of Gynecology," p. 99, 1888.
25
386
A TEXT-BOOK OF GYNECOLOGY.
washed with a douche, and new ones substituted. This simple
method, persevered in, has proved more useful in my hands than
any other yet experimented with.
Granular vaginitis is the most obstinate of all forms to treat,
but when it occurs as a complication of pregnancy it usually
terminates with the pregnancy. Montgomery recommends the
thermo-cautery for the purpose of destroying the papillæ. Unless
used with the utmost caution this strikes me as a dangerous ex-
pedient.
When vaginitis becomes chronic and there is much relaxation
of tissue, applications of tannin and alum are often decidedly
beneficial.
Therapeutics of Vaginitis.
Aconite.-Non-specific vaginitis resulting from cold, espe-
cially in the beginning of the attack; painful urging to urinate;
the vagina is hot, dry, and sensitive.
Belladonna.-Shooting pains in internal organs at every step;
dryness of vagina, with burning and stinging; URGING, AS IF
EVERYTHING WOuld be forced FROM THE VULVA; aggravated by
sitting bent and walking; ameliorated by lying down and sitting
erect; fever with marked cerebral symptoms.
Mercurius .cor.-Inflammation of vulva; vagina swollen, red,
hot, with discharge of watery mucus, then of mucus tinged with
blood; forcing downward as in labor; slight hemorrhage from
vagina.
Cantharis.-Swelling of vulva and vagina with irritation;
burning in vagina and vulva, with a thick, white discharge;
swelling of neck of uterus, with burning in bladder; DYSURIA ;
pruritus of vagina; menstruation too early, with great soreness
of breasts.
Sepia.-Soreness of labia, perineum, and between thighs, with
redness; yellow leucorrhea, ACRID BEFORE MENSES, WITH SORENESS
of pudenda; purulent leucorrhea; symptoms of pressure as if
everything would protrude from the vulva, with all-gone sensation
at pit of stomach.
Hydrastic can.-Chronic specific vaginitis associated with
ulceration of the cervix and prolapse of the uterus; thick,
VAGINITIS.
387
tenacious leucorrhea; vaginitis is associated with great prostra-
tion and palpitation, or with derangement of the liver, giving
rise to constipation, hemorrhoids, etc.
Kreosote.-ITCHING AND SMARTING IN THE VAGINA, WORSE AT
NIGHT; GENITALS SWOLLEN AND HOT; ON URINATING, SORE PAINS
IN VAGINA; voluptuous irritation deep in vagina; white discharge
from vagina preceded by pain in small of back; yellow leucor-
rhea staining linen, with weakness in legs; great acridity of
leucorrhea, which causes itching and biting of external genitals.
Arsenicum.-Shooting pains from the abdomen into the
vagina, with profuse yellow, corroding leucorrhea; sudden
profuse discharge of dark blood from vagina; menses too early
and too profuse, or pale and scanty; PROSTRATION AND EMACIA-
TION.
Calcaria carb.-Scrofulous diathesis; MENSTRUATION TOO
EARLY AND TOO PROFUSE; general weakness with exaggerated
desires; constant aching in the vagina; profuse leucorrhea like
milk; burning in labia before menstruation; discharge of bloody
water from vagina in elderly women, with pain in small of back,
as if menses would appear.
Helonias.-Offensive leucorrhea; very little exercise tends
to produce a flow of blood; vaginitis with uterine prolapse and
a sensation as though there were a heavy weight over the chest,
on the sternum, and a feeling as though the chest had been
gripped in a vice (Farrington); persistent itching about the
genitals, with or without the formation of blisters or sores;
aphthous vaginitis and erythema of external genitals (L. L.
Danforth).
Thuja.-Extreme sensitiveness of vagina; mucous leucor-
rhea; cauliflower excrescences, bleeding freely; condylomata
which are moist, suppurating, and give rise to an exceedingly
offensive discharge.
Sulphur.-Menses too late, of short duration, or suppressed;
bearing down in vulva toward genitals; leucorrhea of yellow
mucus, corroding and preceded by pains in abdomen; tendency
to eruptions.
Consult:-Rhus tox, conium, kali carb., croton tig., cimici-
fuga, gelsemium, and kali mur.
CHAPTER XXVII.
SENILE OR ADHESIVE VAGINITIS.
General Considerations and History.-The dearth of liter-
ature treating of this subject fully justifies, I think, the insertion
in full of the following, which was first published in the Homeo-
pathic Journal of Obstetrics for March, 1889.
Dr. Alfred McClintock, at the June 11, 1870,* meeting of
the Dublin Obstetrical Society, presented a paper entitled
"Senile Contraction of the Vagina," in which he describes
certain pathological changes corresponding to those resulting
from the type of inflammation designated by the title of this
chapter.
FIG. 66.

Section of VAGINA; c, c, Cicatricial Bands.† (Wood.)
Dr. McClintock first refers to the frequency of contractions,
contortions, and occlusions of the vagina resulting from cica-
* Dublin Quarterly Review, vol. L, p. 17.
†The patient from whom this illustration was taken presented herself at the University
clinic with complete laceration of the perineum, the rent in the recto-vaginal septum
extending to the cicatricial projection. Before the laceration could be repaired I
found it necessary to overcome the contractions by cutting them and dilating the
vagina. My object in presenting this cut is to show, by contrast, the difference between
this not unusual form of contraction and cicatrization and the rarer types seen in Figs.
67 and 68, which McClintock and two or three other writers have described under
different names.
388
SENILE OR ADHESIVE VAGINITIS.
389
trices and adhesions.
sloughing of the vagina are familar to all practical gynecologists
and obstetricians, as are also those minor forms of contraction
resulting from projecting transverse folds, which present to the
finger a sharp, crescentic edge like that shown in Fig. 66.
These sequelæ of inflammation and
In the paper referred to, the writer next reminds the reader of
the well-known fact that the upper part of the vagina is, normally,
both capacious and distensible. In both married women and in
virgins the finger can be passed freely into all of the fornices,
between the cervix and the vaginal walls. In the peculiar form
of vaginitis under consideration the conditions are quite altered.
"There is," says McClintock, "a progressive diminution of the
caliber of the vagina-not throughout its entire extent-
but commencing at its summit and slowly advancing downward.
When the contraction has reached the level of the os tincæ, the
introduction of the finger into the vaginal cul-de-sac around the
cervix becomes quite impossible, this part (cervix) being so
closely embraced by the broad, ribbon-like structure. With
the persistent increase of the constriction the os and cervix
become quite encapsulated, and beyond the reach of touch or
sight. The foramen through the stricture, in two of my cases,
was so small as barely to admit a probe, and might very readily
have been mistaken for the os uteri itself. How much lower
down this process of contraction may extend I cannot at present
say, the cases which have longest been under my observation
being married women, and I should imagine that sexual inter-
course would tend to hinder or retard the progress of the con-
traction downward."
Simpson,* in a chapter devoted to "Closure and Contraction
of the Vagina as a Result of Inflammation, and Independently
of Pregnancy," introduces his subject by describing, first,
those forms of vaginal inflammation occurring oftener in chil-
dren, and which result in contraction and closure of the canal
at its lowest point. This form of inflammation is also frequently
met with and is easily recognized. I desire, nevertheless, to
quote in detail from Simpson: † "You may meet likewise among
* "Diseases of Women," vol. III, p. 269.
† Ibid., p. 260.
390
A TEXT-BOOK OF GYNECOLOGY.
adults with cases of a kind of adhesive or obliterative vaginitis
of an analogous type. But the disease in adults differs from the
disease in infants in one or two important respects. In infants
the inflammatory closure is usually limited to the very orifice of
the vagina, and produces complete occlusion of the canal. In
adults it generally commences at the upper part of the vagina,
and spreads gradually downward, and seldom causes complete
closure. In infants there is commonly cohesion merely of the
apposed sides of the orifice of the vagina, without any tendency
to circular contraction in the caliber or circumference of the ori-
fice. In adults, on the contrary, a state of inflammatory cohe-
sion and obliteration is almost always attended with a simulta-
neous tendency to circumferential contraction of the canal at the
site of the disease, so that when it is limited, as it often is, to
the top of the vagina, the os uteri is felt drawn up, as it were,
to the apex of a narrow, conical, or funnel-shaped cavity.
There is evidently a tendency in some rare cases to the occur-
rence of obliterative inflammation of the uterine canal itself; for
FIG. 67.
CONTRACTED VAGINA.
Dotted line showing normal
outline of Vagina. (Wood.)
in the instances I refer to you may
open up the canal repeatedly with the
uterine sound, and yet the patients will
occasionally come back to you with
perfect amenorrhea, and when you pass
the sound along the canal you will
have the sensation imparted to you of
the instrument separating the adher-
ent surfaces, just as you can feel the
adhesions of the vagina separating
under the pressure of the finger."
McClintock's paper was published
in 1870. Simpson's work was not
issued until 1872, but the editor, A.
R. Simpson, states, in his preface, that
"the greater number of lectures con-
tained in this volume appeared in the
Medical Times and Gazette during the
years 1859-1861." Whether or not
this particular lecture was published at that time I do not know.

SENILE OR ADHESIVE VAGINITIS.
391
At any rate, McClintock makes no reference to it in his paper.
I have thus quoted somewhat at length from these two writers,
because they are the only ones in the whole range of literature
which I have traversed who give anything like a comprehen-
sive description of the peculiar and not altogether rare condition
under consideration.
Prof. A. J. C. Skene presented in 1877 a most admirable essay
to the American Gynecological Society on "Cicatrices of the
Cervix Uteri and Vagina."* In it the author deals especially
with those forms of contraction occurring below the fornix
vaginæ which result usually from parturition. Three clinical
cases are recorded by Skene, one a nullipara who had during
childhood what was supposed to be a "typho-malarial " fever,
followed by pelvic inflammation and abscesses—a point worth
noting in connection with the cases whose records I shall pre-
sent. In this essay no mention is made of McClintock's and
Simpson's articles; nor does Skene in his latest work † have
anything to say of "adhesive vaginitis."
Bedford, in a series of clinical cases, describes adhesions of
the upper portion of the vagina caused by the unskilful use of
instruments, but an analysis of these cases shows them to he
not unique in their pathology.
May,§ evidently deriving his information from Fritsch, dis-
misses the whole subject in six lines.
Tilt || refers to "vaginal contraction" as a result either of trau-
matism or chemical irritants, but says nothing more.
Sims ¶ treats of certain unnatural conditions of the vaginal
vault, either congenital or acquired, giving rise to sterility, but
he conveys to the reader no definite idea of the peculiar vaginal
deformity under consideration.
Fritsch,** on the other hand, evidently looks upon the lesion
* "Transactions," vol. I, p. 91.
t "Diseases of Women," 1889.
‡ "Clinical Lectures on Diseases of Women and Children," pp. 347 and 379.
8
"Manual of Diseases of Women," p. 79.
“A Handbook of Uterine Therapeutics," p. 241.
T "Clinical Notes on Uterine Surgery," p. 342.
** "Diseases of Women," pp. 96 and 98.
392
A TEXT-BOOK OF GYNECOLOGY.
as a pathological entity, giving a brief but very good description
of it.
*
Byford's description of vaginal cicatrices is confined to those
varieties where there is a "frenum-like projection in the vaginal
walls," such as is depicted in Figure 66.
Hart and Barbour † say: "The cicatricial contraction of the
vagina observed after the menopause is due to senile vaginitis.
The epithelium is shed in patches, and the raw surfaces thus
produced adhere together (Hildebrandt). This process is similar
to that which produces occlusion of the cervical canal after the
menopause."
Southwick, in his schema of the several varieties of vaginitis,
FIG. 68.

THE RIGHT AND ANTERIOR FORNICES OBLITERATED, the Left FREE. (Wood.)
briefly refers to the senile or adhesive, asserting that" there may
be no subjective symptoms whatever."
Breisky § has a very interesting chapter upon “Acquired
Atresias and Stenoses," and refers to Simpson's article. He
offers no observations of his own bearing upon senile vaginitis.
Cowperthwaite || gives in substance the brief reference to the
condition made by Hart and Barbour, quoting indirectly Hilde-
brandt's article.
*"The Practice of Medicine and Surgery, Applied to the Diseases and Accidents
Incident to Women," 2d Edition.
+
"Practical Manual of Gynecology," p. 495.
"Practical Manual of Gynecology," p. 115.
80 "Diseases of the Vagina," p. 264.
|| "A Text-Book of Gynecology," p. 98.
SENILE OR ADHESIVE VAGINITIS.
393
Winckel,* under the head of " Senile Changes of the Uterus,"
says: "With the approach of the menopause the uterus begins
gradually to decrease in size, at the same time the fornices of the
vagina become shorter and narrower and are finally obliterated.
The vaginal vault becomes narrowed, thus giving the vagina a
funnel shape as it approaches the cervix. . . The lips of the ex-
ternal os and the mucous membrane of the internal os lie firmly
together, thus preventing the free exit of the secretion, which
abundantly accumulates first in the cavity of the fundus, next
in the cavity of the cervix, and finally in the narrow vault of the
vagina." Winckel gives several interesting illustrations taken
from photographs of post-mortem specimens. These, however,
do not show the characteristic vaginal changes of the affection
under consideration.
The foregoing literature is the sum total bearing upon the
subject which I have been able to discover. For fear of appear-
ing pedantic I shall refrain from naming the many works ransacked
in my research, which was not confined to gynecological and ob-
stetrical literature alone, but included many miscellaneous vol-
umes, society transactions, etc., etc. I have not, however, had
access to the article of Hildebrandt, quoted by Hart and Barbour.
Diagnosis and Prognosis.-There may be some difficulty
in differentiating the affection from malignancy. Indeed, such
an error is recorded by Byford. The history of the case, the du-
ration of the pelvic symptoms, and the local condition described,
should be noted in forming a diagnosis. By carefully observ-
ing the peculiar funnel shape of the vagina, the obliteration of
the fornices and the absence of involvement of the surrounding
tissues, it should not be mistaken for malignancy. There are
no features of the lesion suggesting an unfavorable prognosis
so far as life is concerned; it may, nevertheless, prove a most
obstinate one to treat.
Etiology and Pathology.-In 1870 McClintock wrote: "Al-
though years have elapsed since I recognized this state of the
vagina as a distinct lesion, I can give but a very imperfect
account of it. I know nothing of its etiology, nor have I had
* "Die Pathologie der Weiblichen Sexual-Organe," 1881.
394
A TEXT-BOOK OF GYNECOLOGY.
an opportunity of making an anatomical examination of the
parts affected, so that I am equally ignorant of its pathology."
Even in the light of our present knowledge, we can speak
positively concerning neither the etiology nor the pathology. It.
is worthy of note, however, that in two of my own cases, and in
one case recorded by Skene, serious pelvic symptoms dated
from an attack of continued fever. There is abundance of
corroborative testimony showing that any low fever may cause
alarming vaginitis with cicatricial contractions lower down in the
canal. White and Nélaton have traced such contractions to
cholera; Scanzoni, Hening, and Richter to acute exanthemata;
Martin, L. Mayer, and Bohm to typhus. The history of a low
or continued fever of any kind should not, therefore, be lost
sight of in looking for etiological factors, though a larger series
of cases than has yet been recorded will be required to determine
this point, and the cause will, in many cases, remain obscure.
If, in the cases presented by myself, the disease was the sequel
of fever, the term senile vaginitis is clearly a misnomer. On
the other hand, it is hard to explain why, in advanced age,
the fornix vaginæ should take on inflammatory action when all
forms of irritation are wanting. Fritsch* observes that cervical
catarrh has complicated every case of vaginitis adhesiva seen by
him. It is well known, too, that the layer of pavement epithe-
lium becomes gradually thinner as age progresses, thus facilita-
ting an extension of the catarrh from the cervix to the vagina.
The inflammation may be universal or circumscribed. In
either event granulating surfaces form in the vaginal fornices
which cause them to adhere to the cervix. In this way" the
vaginal portion may partially adhere to the fornix, so that iso-
lated cords can be felt; or totally, so that the vaginal portion
cannot be felt at all." (Fritsch.) Hildebrandt observes that very
similar adhesions may occasionally result from ulcerative vagi-
nitis, and where they are firm it is probable that a more destruc-
tive process than mere abrasion has existed. Again, it would
hardly be possible to have the degree of contraction shown in
Fig. 67 without secondary cellular infiltration (Ziegler) into the
* Op. cit.
SENILE OR ADHESIVE VAGINITIS.
395
connective tissue of the mucosa, and often, also, of the sub-
mucosa. The existing conditions are difficult to explain on any
other hypothesis.
Treatment.-There is but little said in the limited literature
concerning the management of adhesive vaginitis, and my ex-
perience with the disease will warrant me in doing nothing
more than suggesting certain general indications. These are:—
1. If the morbid process has given rise to no distress or in-
convenience, let it alone.
2. If there is cervical occlusion with uterine tenesmus and
general pelvic distress, the stenosis should be overcome.
3. Subdue the existing inflammation and promote absorption
of cellular infiltration: (a) by the hot douche; (b) by the medi-
cated cotton-wool tampon.
4. Separate adhesions with the finger, knife, or scissors, when
the cicatrices interfere with the functions of the bladder or the
bowels, or when dyspareunia becomes a prominent symptom.
5. Control reflex and constitutional symptoms with the in-
dicated remedy.
Illustrative Cases.
CASE LVII.—A maiden lady, 52 years of age. Never has been strong. Com-
menced to menstruate at thirteen, but was very irregular until sixteen, for which
irregularity she frequently took "tansy tea." Until the age of twenty she had frequent
attacks of epistaxis, and has occasionally bled from the nose since that time. During
her girlhood hysteria was a frequent symptom, particularly before or during the men-
strual period; the hysterical explosions were not infrequently followed by decided
choreic manifestations, implicating the head, face, and upper extremities. Her menses
were fairly regular until the age of thirty-five, at which time she had an attack of what
her physician called "typho-malarial fever." Her menses were always more or less
scant, and were attended with a good deal of pain. She ceased menstruating two
years ago. Her attending physician during the attack of fever was a "Thomsonian."
He administered a powerful lobelia enema which excited the most aggravated retch-
ing and vomiting, the patient declaring that she vomited some of the injection. At
any rate, the prostration following this heroic treatment was both profound and alarm-
ing, and she got up from a lingering illness with much pelvic distress. From that
time on there has been an aching, pressing, bearing-down sensation in the pelvis, with
dysuria, hemorrhoids and prolapse of the rectum. Indigestion from girlhood has
troubled her much, there being times, lasting for days or weeks, when the stomach
will immediately eject everything. These attacks of vomiting have recurred at
variable intervals up to the present time. The food is vomited undigested soon after
eating and with but little retching. There is at all times a great feeling of satiety
396
A TEXT-BOOK OF GYNECOLOGY.
after a few mouthfuls have been swallowed. The patient is very nervous, suffering
much from occipital headache, flushes of heat, and insomnia, the latter symptom
being aggravated by the menace and worry incident to the care of a large estate.
Upon making a local examination I found the condition represented in Figure 67. As
the finger passed into the vagina there was no perceptible induration to the touch, such
as is found in constrictions following inflammation with decided cellular infiltration
or sloughing (Figure 66). There was, however, a decided narrowing of the caliber
of the vagina, this narrowing being much more marked at the os tince than below,
so that the canal was funnel-shaped. The fornices of the vagina were entirely obliterated,
and the cervix could not be found. Owing to the necessarily unsatisfactory bimanual
I at first thought that the uterus was absent. Upon introducing a small virgin specu-
lum (Nott's) the entire surface of the vagina was seen to be intensely red and con-
gested. A fair idea of the degree of contraction present at the cervix can be had
when it is stated that the blades of the speculum could not be separated more than
half an inch. There was a small opening corresponding to the external os, but the
cervical canal proper was entirely obliterated. Subsequent treatment reduced the
tenderness and inflammation so that I succeeded in opening the canal, hoping thereby
to relieve the tenesmus and bearing-down sensation. The parts have, under the treat-
ment outlined, improved greatly, and the small infantile cervix has been freed from its
encapsulation. I should have added that the uterine body is unnaturally small and
anteflexed.
CASE LVIII.—Mrs. C., æt. 52, and the mother of ten children. This patient pre-
sented herself at the clinic of Prof. D. A. McLachlan, on February 8, 1889. Her
father died of phthisis, and her mother of cancer. She has three sisters and four brothers,
all living. She, also, has dyspeptic trouble dating back to early childhood, for the relief
of which she came to Ann Arbor. There is a history of typhoid fever in early life,
though the stomach trouble existed before the onset of the fever. Her indigestion
frequently gives rise to vomiting, and there is, and has been for years, a persistent
acidity of the stomach with water-brash. There is much flatulence with faintness, and
an all-gone sensation at the pit of the stomach. Menstruation ceased three years
ago. She suffered much from dysmenorrhea, and has had for years marked pelvic
distress. I was requested to make a local examination, and found what is very
accurately depicted in Figure 68. The upper and right fornices were not obliterated
though not as deep as normal; the lower and left were, on the contrary, entirely
effaced by the gluing together of the opposing mucous surfaces. The os tince was
somewhat dilated, and the cervix had suffered a stellate laceration. The vagina
was much narrower than normal, though not as small as in Case LVII. I could not
get a good view of the parts with the speculum, but there was much redness and
congestion. The patient returned to her home in the interior of the State, and it
is not likely that another opportunity for an examination will present itself.
The patient, a
CASE LIX.-I regret that I cannot furnish full notes of this case.
woman 55 years of age, was sent to me for examination by Doctor Mary E. Havens
of St. Johns, Michigan. She had had a number of children, and there was much
mental and nervous trouble, symptoms of insanity causing her friends much anxiety at
times. She came to me with an attendant. There was a history of "inflammation
of the bowels," which was probably cellulitis. There was also a bad leucorrhea, and the
SENILE OR ADHESIVE VAGINITIS.
397
patient complained much of stinging, burning pains in the region of the uterus and
the ovaries. An examination revealed the vagina shaped not unlike that shown in
Figure 67, with an evident bi-lateral laceration of the cervix. Her physician in-
formed me, some twelve months after my examination, that the local condition had
quite disappeared under treatment, and that the patient had greatly improved both
mentally and physically.
CHAPTER XXVIII.
ACUTE INFLAMMATORY DISEASES OF THE
UTERUS, THE UTERINE APPENDAGES, AND
OF THE PELVIC PERITONEUM AND
CELLULAR TISSUE.
My experience as a teacher of gynecology convinces me that
there is nothing more confusing to the student of medicine than
an attempt to follow the ordinary text-book classification of the
various inflammatory affections of the uterus and its surround-
ing structures; and my experience as a practitioner of gyne-
cology is that the time-worn classifications and divisions, while
serving a very good purpose on paper, are frequently valueless
at the bedside. Acute inflammation of the uterus, were it ever
confined absolutely to the endometrium or the parenchyma of
the organ, would require practically the same treatment in either
event, and, indeed, the treatment of acute endometritis and
metritis is not essentially different from that of acute cellulitis
and peritonitis. There is in most instances a blending of the
pathology of the various acute inflammatory affections of the
pelvic organs; and, so far at least as the subjective phenomena
are concerned, there is likewise a blending of the symptoms. It
is this fact which is so confusing to the ordinary student. In
studying in succession, and as distinct and separate lesions, acute
and chronic metritis, acute and chronic endometritis (cervical
and corporeal), salpingitis, ovaritis, cellulitis, and peritonitis, he
becomes utterly swamped in the uncertainty of differentiation.
I maintain that this method of teaching is illogical and unscien-
tific. The teacher or writer has no right to expect from the
student of medicine more than can be done by himself at the
bedside. I therefore deem it more practicable to classify the in-
flammatory affections of the uterus and periuterine structures
according to the acuity or chronicity of the symptoms which
398
ACUTE METRITIS AND ENDOMETRITIS.
399
characterize them, believing both clinical manifestations and
pathological blendings justify such a classification. It is for this
reason that I have grouped together the several affections em-
braced in this chapter.
ACUTE METRITIS AND ENDOMETRITIS.
Metritis and endometritis are terms used to designate respect-
ively inflammation of the parenchyma of the uterus, and of its
lining membrane or endometrium. In most of the text-books
these disorders are treated of as separate and distinct, and yet,
when so dealt with, a comparison of the symptoms of the two
affections will show a similarity making them indistinguishable
the one from the other, even on paper.
The anatomy of the uterus is peculiar, and the relationship of
the mucous membrane to the underlying muscular structure
differs from that of mucous membranes in general. The mu-
cous membrane is, first of all, more dense in character, and it is
not separated from the parenchyma by the layer of areolar tissue
which underlies most mucous surfaces. Again, the numerous
glands which go to make up the mucous membrane are im-
bedded more or less in the muscular layer. Acute inflammation
of the endometrium will, therefore, inevitably implicate the uterus
proper; and, conversely, acute metritis cannot run its course
without involving the endometrium to a greater or less extent—
hence the absurdity of studying the two conditions as distinct
affections.
Causes. Any of the following causes may give rise to the in-
flammation: Sepsis resulting from parturition" or miscarriage;
traumatism resulting from instrumental interference or from
immoderate coitus; menstrual suppression; extension of inflam-
mation from the vagina or the surrounding cellular tissue;
exanthemata.
Sepsis is undoubtedly the most frequent cause, and the inflam-
mation resulting from it may be of the most virulent character. In
the larger number of instances it is due to improper management,
either on the part of the physician or the patient, during partu-
rition or miscarriage. Retained membranes or clots soon
become putrid and set up inflammation with absorption of sep-
400
A TEXT-BOOK OF GYNECOLOGY.
tic matter; or the source of sepsis may be the débris result-
ing from an effort to remove fibroids. In miscarriages inflam-
mation is often induced by getting up too soon.
It will require
another decade to educate the laity to the necessity of proper cau-
tion after miscarriages. The average woman imagines that early
abortions require but a short period of rest, and, accordingly,
she gets on her feet while the uterus is yet heavy and congested.
In this state it is only a step to actual inflammation and, if clots
or membranes have been left behind, sepsis frequently super-
venes.
Non-puerperal inflammation of the uterus rarely runs so in-
tense a course as does the puerperal form of the disease. As a
complication of the exanthemata it may, however, be very severe.
Some women seem peculiarly prone to the difficulty, even the
introduction of the uterine sound giving rise to metritis. This
is probably because of pre-existing chronic inflammation.
Pathology. The essential pathological changes are: great
hyperemia of the endometrium, which becomes swollen and
softened as a result of edema; infiltration of the subjacent
uterine tissue with ecchymoses and, occasionally, small deposits
of pus between the muscular fibers; involvement to a greater
or less extent of all of the uterine veins and lymphatics. A
large accumulation of pus in the uterine wall is of exceed-
ingly rare occurrence, though such a case is recorded by
Tait.*
Symptoms.-The disorder gives rise to symptoms of varying
intensity, depending largely upon the cause, and the extent of
tissue involved. * In non-puerperal cases, and especially in those
due to an extension of the disease from the vagina, the symptoms
are not usually urgent. A slight chill ushers in the attack,
which is followed by a moderate increase of temperature. The
patient will complain of a throbbing pain in the hypogastric
region, together with more or less weight and bearing down.
The bowels and bladder may become implicated, giving rise to
more or less tenesmus and dysuria. On the whole, the constitu-
tional symptoms are not severe, and the disease frequently passes
* "Diseases of Women and Abdominal Surgery," p. 122, 1889.
ACUTE METRITIS AND ENDOMETRITIS.
40I
into a chronic form without arousing serious apprehension on
the part of either physician or patient.
On the other hand, when the cause is septic and the inflamma-
tion is puerperal in its origin, it is of most serious import, and,
indeed, often fatal. The initiatory chill is marked and is followed
by high temperature, rapid pulse, and much local tenderness.
The lochia and milk become suppressed and the whole system
is profoundly impressed by the septic invasion. The patient
often complains of great pain in the back, which radiates to the
groin and thighs. The disease frequently involves the peritoneum,
when there will be much distention and tenderness with nausea
and vomiting. The characteristic peritoneal facies presents, the
breath is of a peculiarly sweetish and sickish odor, the prostra-
tion becomes more and more profound, and death only too often
results.
In the non-puerperal cases the discharge is first thin or viscid,
but in the course of several days it becomes muco-purulent or
purulent. Not infrequently it is exceedingly excoriating and,
especially if there be a septic tinge, offensive.
A physical examination will reveal at first dryness and heat of
the vagina with tenderness of the cervix. The uterus is large
and heavy. If it can be gotten between the two hands this
increase in size and weight is very perceptible.
Differentiation.-There is but one pathognomonic symptom
of uncomplicated acute metritis and endometritis, which will serve
to distinguish it from pelvic cellulitis and peritonitis, namely,
swelling and tenderness of the uterus with mobility of the organ.
It is the height of nonsense to affirm, as is done by so many
authors, that the constitutional symptoms of puerperal metritis
are not so marked as those of pelvic cellulitus and peritonitis. I
have many times observed in metritis symptoms infinitely more
profound than those resulting from non-puerperal peritonitis
and cellulitis, and when it is remembered that metritis is often
complicated by para-and-peri-uterine inflammation the uncer-
tainty is increased beyond all differentiation by subjective phe-
nomena alone. I admit that cases of metritis, cellulitis, peri-
tonitis, etc., are occasionally met with, running a course suffi-
ciently distinct and characteristic to enable the attendant, by the
26
402
A TEXT-BOOK OF GYNECOLOGY.
aid of both the clinical history and a thorough physical exploration,
to determine the organ or tissues chiefly involved, and for this
reason I shall soon introduce a differentiating table. Unfortu-
nately, thorough physical exploration is the last thing to be
thought of in dealing with severe pelvic inflammation of an
acute character. While granting that refinement of diagnosis is
something always to be desired, in the several acute affections
now under consideration it is useful as a means of determining
the prognosis rather than as a guide for treatment.
The prognosis will depend entirely upon the character and
extent of the inflammation. In the milder attacks of non-puer-
peral metritis it is favorable, though the patient is often left with
a chronic endometritis which may continue almost indefinitely.
On the other hand, septic metritis and endometritis are always
of serious import, and, if associated with the puerperium, fre-
quently result fatally. The prognosis is, of course, modified by
the existing complications.
ACUTE PELVIC CELLULITIS AND PERITONITIS.
Since the days of Morgagni, who first attracted attention to
pelvic peritonitis by placing on record a case in which adhesions
were found, post-mortem, between the right ovary and tube and
the colon, and the days of Doherty and Marchal de Calvi, to
whom we are indebted for the first intelligent description of
pelvic cellulitis, there has existed the greatest confusion regard-
ing these two disorders. As in acute inflammation of the uterus
and its lining membrane, we have two structures which, though
histologically different, are in such close contiguity as to make
it impossible for the one to become involved in the inflammatory
process without implicating, to a greater or less extent, the other
also, and, indeed, all of the pelvic organs-hence the confusion.
I grant that in studying these diseases from the standpoint of
pathology we find abundance of evidence showing that acute in-
flammation may spend its greatest force upon either the pelvic
cellular tissue or its investing serous membrane. Furthermore,
I grant that, when this is the case, the clinical picture may be
such as to enable us to determine which structure is chiefly in-
volved. All this is desirable from the standpoint of pathology
ACUTE PELVIC CELLULITIS AND PERITONITIS.
403
and diagnosis, but I contend that the two diseases are so often
blended as to make this knowledge of but little value to the
clinician. The fact remains that, when the clinician goes to the
bedside of a woman suffering with acute inflammation of any of
the pelvic organs, he is confronted with a condition which demands
of him certain duties: first he is required to determine the cause
of the mischief and remove that cause as speedily as possible;
secondly, he is to contend with the expressions of the disease
to which the cause has given rise. The same cause may in one
instance result in metritis, while in the next it may give rise to
cellulitis or peritonitis.
We may, then, be unable to determine the exact pathological
changes that have taken place within the pelvis, but, from the
standpoint of treatment—and the chief aim of the physician is
to cure disease that he cannot prevent-this is not important.
In making this statement I am not drawing deductions solely
from my own school of medicine, for, in comparing the treat-
ment of the several diseases under consideration given by the
principal writers of the older school, it will be found that, while
the treatment is as variable as the writers are numerous, each
practically observes the same principles of treatment in dealing
with all forms of acute pelvic inflammation.
Modern abdominal surgery has taught us much regarding
pelvic inflammation. I have more than once opened the abdo-
men expecting to find this or that product of inflammation, only
to discover that an entirely different lesion existed. I make this
confession unblushingly, for such men as Tait, Bantock, and
others of equal eminence, admit the utter impossibility of deter-
mining, in the vast majority of instances, the actual changes
resulting from pelvic inflammation before the abdomen is
opened.
In dealing with the sequelæ of inflammation we can conduct
the examination under the most favorable circumstances. We
can, if necessary, paralyze the abdominal walls with an anes-
thetic and bring the pelvic contents within the grasp of the
hands. It is, nevertheless, a notorious fact that, notwithstanding
the resources permitted by the chronicity of the condition, cer-
tainty of diagnosis is often impossible. How utterly foolish it
404
A TEXT-BOOK OF GYNECOLOGY.
is, then, in the acute affections, in which we have to rely for
diagnosis largely upon subjective symptoms, to affirm dogmatic-
ally that this or that tissue or organ is the one chiefly involved!
Confusion will inevitably result from such teaching. The
student may go to the bedside with a vivid recollection of the
parallel differentiating columns given to him by his professor,
but he will return from it with a full consciousness that clinical
phenomena blend with an obstinate disregard for prescribed
rules.
I cannot better illustrate the wide difference of opinion that
prevails regarding pelvic cellulitis and peritonitis than by quot-
ing, somewhat in detail, from two of the latest text-books on
gynecology published in the English language. Much the
same diversity of opinion prevails in the French and the German
literature. Lawson Tait says:
says:—*
"In the employment of the terms' perimetritis' and 'parametritis,' as introduced
by Virchow (who knew nothing of gynecology), and advocated by Matthews Dun-
can (who has never had his fingers inside the pelvis from above), we have had intro-
duced a wholesale confusion into gynecology which will take many years yet of in-
dustrious work to get right. The confusion has been vastly aided by Dr. Emmet's
teachings about 'cellulitis.' If 'parametritis' and 'pelvic cellulitis' be relegated
to their proper place—and they may be taken to mean the same thing—it is one
of the rare conditions we have to deal with among the special ailments of woman.
"Perimetritis is a much more fatal disease than is parametritis, and occurs with
greater frequency in association with two particular conditions. These are parturition,
either at the full time or prematurely, and gonorrheal infection.
"Before the light came that was shed on these ailments by modern abdominal
surgery, I believed, as others did and do still, that parametritis, or pelvic cellulitis, was
a common disease; and in my writings up to 1878 it is evident I confused cases of
damaged uterine appendages with 'pelvic cellulitis.' The latter disease is rare, and
occurs in two forms, depending for their characters upon the situation of the disease.
If it is situated on the inner half of the broad ligament it is to be recognized as a mass
lying close to the uterus and in front of it, between the uterus and the bladder, and
into the bladder it generally bursts. If it exists in the outer half of the broad liga-
ment it is to be recognized as an ill-defined mass, lying at the brim of the pelvis and
fading off on that ridge. In this position it bursts over the brim of the pelvis and
constitutes the familiar pelvic abscess, whose sinuses go on for years. Suppurating
hematoceles of the broad ligament have similar endings. Rarely does the abscess
open into the rectum, because it is generally situated far above the rectum and in
front of it."
***
Diseases of Women and Abdominal Surgery," p. 131, 1889.
ACUTE PELVIC CELLULITIS AND PERITONITIS.
405
I next quote from Thomas and Mundé :-
*
"It has become fashionable of late for many of our most enthusiastic and progres-
sive laparotomists to deny utterly the existence of such a pathological condition as
cellulitis, except in a few rare instances after parturition, and to assume that all cases of
inflammatory exudations in the pelvis, with or without suppuration, are unquestionably
intra-peritoneal; that is to say, that all cases of pelvic peritonitis proceed primarily
from the Fallopian tubes, and involve secondarily the ovary and the adjacent peri-
toneum. Pelvic abscess, as such, exists in the minds of these gentlemen only as a
synonym for abscess of the Fallopian tube (pyo-salpinx), ovary, or pelvic peritoneum,
any one of which may, by adhesion and perforation, force its way into the pelvic
cellular tissue, and thus simulate an abscess resulting from pelvic cellulitis. . . . In
our opinion inflammation of the pelvic cellular tissue, with its resultant consequences
of dislocation of the uterus, pelvic abscess, and cicatricial induration, occurs inde-
pendently by itself, as well as inflammation of the Fallopian tube, ovary, or adjacent
peritoneum, with resultant purulent accumulations in these organs. . . . Pelvic peri-
tonitis and pelvic cellulitis are, in fact, independent and entirely unassociated diseases,
just as pleurisy of one part of the lung may occur at the same time with an inflamma-
tion of the substance of the lung at another point."
The authors last quoted refer to the statistics of Bernuth, who
has recorded the results of "five autopsies by himself, and be-
tween twenty and thirty by others, which presented all the signs
of pelvic peritonitis and none of cellulitis, although during life
the symptoms and signs generally attributed to the latter disease
were present." They, however, question the accuracy of a num-
ber of the cases quoted, but the doubt expressed only adds force
to the argument which I am putting forth. In the first place we
are presented, by so good an authority as Bernuth, with the
record of a large number of autopsies in which, during life, all of
the signs of pelvic peritonitis presented themselves and none of
cellulitis; yet, according to Bernuth, the post-mortem revealed
exactly the opposite condition in every instance, though Thomas
and Mundé reject "a number of cases reported, because not suffi-
ciently conclusive." If such uncertainty prevails in dealing with
post-mortem cases, how ridiculous it is to study, in the living,
pelvic peritonitis and cellulitis as entirely distinct affections.
I have been led, therefore, both by personal experience and by
a careful survey of the literature, to adopt the plan of presenting
conjointly to the student pelvic cellulitis (parametritis) and pelvic
* Op. cit., p. 467.

406
A TEXT-BOOK OF GYNECOLOGY.
peritonitis (perimetritis), emphasizing this or that symptom which
may serve to indicate the tissues chiefly involved, and to treat of
acute ovaritis and salpingitis as complications of general pelvic
inflammation. Pelvic abscess, which may be a sequel of any
form of acute inflammation, and diseases of the appendages,
are more appropriately discussed under other heads.
Anatomy. If the reader will refer to Fig. 12 he will find the
peritoneum, as it is related to the pelvic organs, clearly outlined;
FIG. 69.
Cuvam
pelvic
perito
neale
Cavum
pelvis
Subpert-
toneale
ገባ
subeu
helvis
Lameron
M.levator unt
CROSS-SECTION OF PELVIS. (Luschka.)
and on page 50 will be found a description of the pelvic cellular
tissue. Let the relationship of the two structures be borne in
mind. The cellular tissue surrounds, in greater or less abun-
dance, all of the pelvic organs. It is found between the uterus
and the bladder, the vagina and the rectum, the folds of the
broad ligament, and in the iliac fossæ. It passes by continuity
along the posterior surface of the psoas muscles and separates
in front the peritoneum and transversalis fascia. It is most
abundant between the folds of the broad ligaments; and least so
ACUTE PELVIC CELLULITIS AND PERITONITIS.
407
between the peritoneum and the uterus in front and behind-its
existence in these localities having been denied by some. In the
language of Savage * it “fills up all that part of the pelvic cavity
between the pelvic roof and the floor of the pelvis which is not
occupied by the viscera, and is the sole bond of union between
them." Its function is to steady the pelvic organs and to break
the force of the jar which, without it, would be felt at every
step. Through it the blood-vessels and lymphatics of the pelvis
pass. The peritoneum is everywhere, except along the posterior
surface of the psoas muscles, in intimate contact with it.
In Fig. 69 the peritoneal and sub-peritoneal cavities formed
by this disposition of the cellular tissue and peritoneum are well
shown.
Frequency and Causes.-Periuterine inflammation is of fre-
quent occurrence, and may result from any of the following
causes :
Parturition;
Gonorrhea and extension of inflammation from the uterus;
Intra-uterine and vaginal injections;
Mechanical injuries;
Operations on cervix, fundus, rectum, etc.;
Menstrual suppression;
Rupture of ovarian cysts, extra-uterine gestation cysts, perfora-
tion of the intestine, etc.;
Escape of blood from Fallopian tubes and ovary;
Intraperitoneal surgical operations.
In by far the larger number of cases parturition is the predis-
posing cause. The reasons for this are obvious. Gestation has
brought about a physiological hypertrophy of all of the tissues
of the pelvis-the cellular tissue, peritoneum, blood-vessels,
lymphatics, etc. The lymphatics are in a condition readily to ab-
sorb septic matter if avenues for the same be furnished, and the
frequent lacerations incident to parturition furnish such avenues.
Primiparæ are more often the victims than women who have
borne a number of children, for the reason that lacerations of-
tener occur in the former, and the bruising of the structures
*" Female Pelvic Organs."
408
A TEXT-BOOK OF GYNECOLOGY.
is greater. The disease has its beginning, in the larger per cent.
of cases, on the left side, toward which the occiput is directed in
the majority of births.
We thus see that the changes incident to child-bearing place
the parturient in a state in which the reception of septic mat-
ter easily occurs and inflammation is readily excited. Improper
care on the part of either the physician or the patient at this
time may precipitate an attack of cellulitis or peritonitis.
Uncleanliness is the curse of the lying-in room, and although
modern antisepsis has done much toward diminishing the fre-
quency of this form of puerperal fever,* uncleanliness is still a
frequent source of infection. Indeed, all of the factors given in
obstetric works as causes, either heterogenetic or autogenetic,
of the various forms of puerperal fever, may, under favorable
conditions, give rise to the forms of inflammation now being
discussed. Puerperal septic infection usually first attacks the
uterus and then extends to the periuterine structures.
I have already, in the chapter devoted to vaginitis, dealt in
detail with gonorrhea and its tendency to invade the pelvis. In
the light of present evidence there can be no doubt that gonor-
rhea, starting in the vagina, frequently gives rise to disease of
the tubes, and subsequently to peritonitis and cellulitis.
Intra-uterine injections are so liable to result in mischief that
many specialists have discarded them entirely. Unless used
with the utmost care the fluid is liable to pass through the Fallo-
pian tubes into the peritoneal cavity. One of the sharpest
attacks of inflammation with which I have had to deal came
about in this way.
Vaginal injections immediately after coitus, for the purpose of
preventing conception, are not infrequently responsible for severe
and fatal cases of inflammation. Cold water at this time, and
for the purpose mentioned, is especially harmful and should
never be used.
Operations upon the cervix, fundus, rectum, etc., have more
* The Royal College of Physicians of England has abandoned the term “
puer-
peral fever," and has substituted for it the terms, "puerperal cellulitis,” “puerperal
peritonitis," "puerperal metritis," "puerperal septicemia," "puerperal pyemia," etc.
ACUTE PELVIC CELLULITIS AND PERITONITIS.
409
than once been followed by inflammation of the periuterine tis-
sues higher up. The manner in which the broad ligaments ex-
tend down on either side of the cervix will readily explain why
operations upon the latter so often set up cellulitis in the broad
ligaments. Even slight operations upon the rectum have re-
sulted in fatal cellulitis.
Menstrual suppression, from undue exposure or otherwise, is
an important etiological factor. It is but a step from the physio-
logical congestion of menstruation to inflammation, hence the
danger of an acute suppression.
Rupture of any pathological growth, or of the hollow viscera,
into the peritoneal cavity, first gives rise to peritonitis and then
to cellulitis, except in cases of Fallopian pregnancy which pri-
marily rupture into the folds of the corresponding broad liga-
ment. In the latter event cellulitis is first established, though
it may not be of serious import.
Blood may find its way into the peritoneal cavity through the
Fallopian tube, or by escaping from a ruptured Graäfian follicle.
The amount of irritation excited depends upon the nature and
quantity of the fluid: if it is fresh and bland, the peritoneum, with
its wonderful absorbing powers, will take care of a large
quantity of it without serious trouble; if, on the other hand, it
proceeds from a contaminated uterine cavity, a very small
amount may excite alarming peritonitis.
Pathology. When the pelvic peritoneum is first attacked
(pelvic peritonitis) the membrane becomes hyperemic, red, and
dry. Sometimes the engorgement is so great as to produce a
rough granular condition of the surface, with here and there a
red punctate patch. This is the first stage.
In the second stage the engorgement is relieved by an exuda-
tion of lymph, plastic in character. It glues the apposing sur-
faces together and gives rise to firm adhesions; or the exuded
lymph may be serous, or sero-purulent, in character, gravitating
into some of the pelvic pouches, usually into the Douglas cul-
de-sac. In time this becomes consolidated into a firm, dense
mass, matting together the pelvic organs and forming adhesions
between them and the intestines. The pelvic cavity may be
entirely cut off from the abdominal cavity proper by adhesions

d
FIG 1
FIG 2
PLATE II.
B
FIG 3
B.
*
B.
FIG 4
F165
TOPOGRAPHICAL RELATIONS OF THE PELVIC PERITONEUM AND CELLULAR TISSUE,
SHOWING SEATS OF EXUDATION. (Fritsch.)
Fig. 1. Pelvic Cellulitis.-Vertical section of pelvic organs, showing (e) exudation
into the cellular tissue before and behind the uterus and into the anterior abdom-
inal wall. a-b shows plane of transverse section in Figs. 3, 4, and 5:
Fig. 2. Pelvic Peritonitis.-Vertical section showing (e) exudation in Douglas's pouch,
separated from healthy peritoneal cavity by adhesions.
Fig. 3. Transverse Section Through Normal Pelvis.-u, uterus; r, rectum; b,
bladder; u.-r, utero-rectal ligaments; r. 7, round ligaments; b. 7, broad ligaments.
Light spaces show sections of peritoneal pouches.
Fig. 4. Pelvic Cellulitis.-The same as Fig. 3, with small exudation (e) to left of
broad ligament.
Fig. 5. Pelvic Cellulitis.-The same with large exudation (e) in right broad ligament
extending into the cellular tissue of the anterior abdominal wall, and distorting
the pelvic peritoneal pouches.
ACUTE PELVIC CELLULITIS AND PERITONITIS.
4II
P
thus formed. (Plate 11, Fig. 2.) This condition is sometimes
spoken of as encysted serous perimetritis.
These accumulations may remain indefinitely, distorting the
pelvic cavities and impinging upon the various surrounding
structures; or they may suppurate and burst either externally
or into the rectum, vagina, or bladder. Rupture rarely takes
place into the general peritoneal cavity.
The foregoing are the usual changes. Certain modifications
are, however, of frequent occurrence. In virulent septic cases,
for instance, the fluid, instead of becoming adhesive, is flocculent
and pultaceous, so that the adhesions, not being firm, readily
break down. In the event of recovery the fluid is absorbed.
In all instances the areolar tissue is more or less involved.
In pelvic cellulitis we may also have three stages-congestion,
exudation, and suppuration. Suppuration is, however, absent in
the majority of instances, though it occurs oftener than in
pelvic peritonitis. If a digital examination be made soon after
the onset of the attack, the swelling will be found soft and elastic.
This intumescence is of short duration, and very soon the swell-
ing becomes hard from pouring out of the serum. In the worst
cases the tissues may slough, as occurs in anthrax or phlegmonous
erysipelas.
The extent of the exudation is variable, as is shown in Figs.
I, 4, and 5, of Plate 11. It may be limited to a small tumor in
one of the broad ligaments, which pushes the uterus to the op-
posite side; or it may dissect up the lateral attachment of the
ligament, extending into the cellular tissue of the anterior ab-
dominal wall. Indeed the cellular tissue of the entire pelvis
may become involved, fixing all of the organs immovably.
If resolution ensue, the inflammatory exudates are largely
absorbed, though there is left behind, in the majority of in-
stances, a contractile fibrous deposit. This is cicatricial tissue,
and, if in one of the broad ligaments, draws the uterus to the
corresponding side, thus producing latero-version; or, if in the
utero-sacral ligaments, the contraction draws the cervix back-
ward and, providing the fundus is not bound down, throws it
forward on the bladder.
Suppuration, which occurs oftener in parturient cases, does
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A TEXT-BOOK OF GYNECOLOGY.
not usually ensue before the tenth day. The extent of tissue
destroyed varies greatly, so that the resulting abscess may be
either circumscribed, or large enough to fill the entire pelvis.
The most frequent exit of the pus is above Poupart's ligament;
next in order of frequency come the rectum, vagina, bladder,
anus, and saphenous openings. As in peritonitis, rupture rarely
occurs into the free peritoneal cavity.
It is held by many writers that in non-puerperal cases rupture
externally seldom if ever takes place. This has not been my
observation, for in two cases of pelvic abscess operated upon by
me the patients were virgins. In one there were several si-
nuses and the abscess communicated with the bowel, so that fecal
matter escaped with the pus. Let it be remembered, however,
that in non-puerperal cases suppuration is the exception to the
general rule, and that in most instances pelvic peritonitis and
cellulitis run their course without the formation of pus.
puerperal inflammations, on the other hand, it is claimed that sup-
puration occurs in at least fifty per cent. of all cases. Again, let
what has already been said regarding the blending of the patho-
logy of the two forms of inflammation be borne in mind. As I
have endeavored to show, it is often impossible to determine,
even after the abdomen is opened, whether we have to do with
the sequelæ of peritonitis or of cellulitis.
In
Symptoms.-Acute pelvic peritonitis and cellulitis give rise
to certain symptoms sufficiently characteristic to call for careful
consideration. I nevertheless warn the student that, if he rely
implicitly upon any group of symptoms as pathognomonic of the
condition, he will do so at the risk of being misled. I have
more than once, in both clinical and private practice, met with
cases in which the products of inflammation distorted all of the
fornices of the vagina, though no history of inflammation could
be elicited. And I remember seeing a patient in Leopold's
clinic at Dresden whose entire pelvis was filled with an organized
exudate, yet the woman, a fairly intelligent German, could not
remember that she had suffered from anything more than an
indefinable bearing-down sensation. Patients thus affected seek
relief because of more or less local distress, when an examination
ACUTE PELVIC CELLULITIS AND PERITONITIS.
413
will reveal, what the clinical history does not suggest, the ex-
istence of the products of inflammation.
There can be no doubt, then, that even a severe attack of
pelvic peritonitis or cellulitis may run its course without giving
rise to symptoms of sufficient intensity to attract attention to
the pelvic organs. It may be that in many instances the patient
forgets that at some previous time she suffered more or less pain
and tenderness in the hypogastric region; or, possibly, the indis-
position dates back to some confinement which, for reasons un-
suspected at the time, kept her from convalescing as she should.
In other instances we may be able to ascertain that the patient
has had an attack of "inflammation of the bowels," possibly at
or near the menstrual period, which was nothing more nor less
than some form of periuterine inflammation.
The symptoms which especially lead us to suspect acute pelvic
peritonitis and cellulitis may be enumerated as follows:
Chill;
Fever;
Pain ;
Tenderness;
Vesical and rectal irritation;
Tympanites;
Peritoneal facies;
Nausea and vomiting.
The intensity of the chill is variable and is probably most
marked when the cellular tissue is first attacked. The early
symptoms of inflammation attacking structures of similar forma-
tion throughout the body are generally similar in character.
Thus the characteristic chill of pneumonia is decided, while that
of pleurisy is erratic and slight. In the first instance, we have in
the lungs a structure not unlike the pelvic cellular tissue; while
in the second, the pleura, which is a serous membrane, corres-
ponds to the pelvic peritoneum. Therefore when the peritoneum
is the primary seat of inflammation the initiatory chill may be
nothing more than a sensation of coldness, which is soon for-
gotten.
The thermometric range is quite as variable as is the chill. It
may range from subnormal to 106°, or even higher. In the
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A TEXT-BOOK OF GYNECOLOGY.
worst cases of septic peritonitis it is sometimes sub-normal,
though as a general rule the higher the temperature the more
serious is the attack. This is emphatically so if it remain per-
sistently high, for a long-continued elevation of temperature is
in itself an element of danger. The temperature immediately
following the chill usually ranges from 102°-104°; that of non-
septic peritonitis is somewhat higher than non-septic cellulitis.
The pulse is a much more reliable indication as to the serious-
ness of the attack than is the temperature. The former ranges
from 110-140 and may be full and compressible; or small and
wiry-the characteristic peritoneal pulse. Great rapidity of the
pulse is always an ominous symptom.
*
The degree of pain and tenderness depends in large measure
upon the extent of peritoneal involvement. It may amount to
nothing more than a local distress or bearing-down sensation,
or it may be so intense as to give rise to the most excruciating
suffering. I have seen it so great as to make it almost impos-
sible to quiet the cries of the patient even with full doses of
morphia. It is usually worse when the ovaries and tubes are
involved. The tenderness is often so great over the lower
surface of the abdomen as to make contact of any kind intoler-
able. In peritonitis or bilateral cellulitis both thighs are drawn
toward the abdomen, so as to relax the parts as much as pos-
ible. When the cellulitis is limited to one side the correspond-
ing limb only is retracted.
Vesical and rectal irritation, when present, result either from
direct involvement of the bladder and the rectum in the
inflammatory process, from direct pressure upon them by the
exudates, or from displacement caused by secondary retraction.
There is no more frequent cause of dysuria than shortening of
the utero-sacral ligaments by inflammation. The cervix is
drawn backward and the neck of the bladder is so stretched
that micturition becomes both difficult and painful.
* This statement is not absolutely true in peritoneal surgery. In some of my cases
of abdominal section, in which the convalescence was uninterrupted, the pulse ranged
from 120-140, without any increase in temperature, for two or three days after the
operation.
ACUTE PELVIC CELLULITIS AND PERITONITIS.
415
In septic cases an offensive and prostrating diarrhea may be a
feature of the disease.
Tympanites, the so-called peritoneal facies, and nausea and
vomiting can very appropriately be considered together, because
all depend chiefly upon general peritoneal involvement. The
distention is sometimes very great-so that coils of intestine can
be seen through the tense abdominal walls. Although the
expression is characteristic, it is hard to describe the facies of
peritonitis. There is a peculiar anxiety depicted in the coun-
tenance, which is made more striking by dark areolæ about the
eyes. So long as the disease is limited to the pelvis, nausea
and vomiting are not marked symptoms, unless, indeed, an
inflammatory band has obstructed the bowel, or the ovary is
seriously affected. In general peritonitis, on the other hand,
nausea and vomiting often become most persistent and formid-
able.
Physical Signs.-The extent and nature of the pelvic de-
formity produced can only be determined by careful physical
exploration. For obvious reasons, this must be conducted with
much care. Indeed, if I were satisfied that the uterus did not
contain septic products, I should question the wisdom of under-
taking a thorough examination in acute pelvic inflammation of
any kind. The pain caused by it is usually very great and there
is danger of aggravating the disease. A careful digital examina-
tion at the onset is usually harmless, however, and when the
symptoms become less severe a more thorough examination
may be made.
In the sub-acute forms of inflammation, as well as in those
cases where the formation of pus is suspected, the conditions are
very different and call for careful exploration.
In the very early stage the vagina will be found hot and dry,
with marked tenderness of its vault. This is true in both cellu-
litis and peritonitis.
Should the cellular tissue be the chief seat of the disease, it is
even possible to detect, at the very onset, a soft, edematous
spot which indicates the point attacked. This stage is of short
duration, and rarely is the examination made early enough to
discover it.
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A TEXT-BOOK OF GYNECOLOGY.
After infiltration has taken place the uterus is usually found
displaced and fixed. It may be directed backward, forward,
laterally, or downward, depending upon the location and the
extent of the effusion. To the touch the inflammatory tumor
gives a hard, unyielding sensation, and if the effusion surrounds
the cervix, it may impinge upon the vaginal fornices to such an
extent as almost to conceal the os uteri. By conjoined manipu-
lation and percussion the extent of the effusion can be determined.
It may dissect up the peritoneum as high as the umbilicus.
Examination per rectum will many times afford valuable infor-
mation. The posterior surface of the uterus can be reached and
the extent of the effusion in this locality determined. If the
utero-sacral ligaments are involved they will be felt as two tense
bands on either side. Sometimes the inflammation has extended
to the perirectal areolar tissue, so that the finger will detect a
distinct collar surrounding this organ.
Should pus have formed, the tumor will be more or less
softened and fluctuation can be detected.
The physical changes of pelvic peritonitis vary somewhat from
those just given. The general adhesions are usually more
extensive, but peritoneal inflammation does not so often give
rise to the formation of a distinct tumor. During the early
stage any manipulation of the uterus excites intense pain.
The hypogastric tenderness is most marked. If the effusion is
great it usually gravitates into the posterior cul-de-sac, becomes
organized, and can there be felt as an ill-defined mass; or, espe-
cially in septic cases, it may remain fluid, being shut off from the
general peritoneal cavity by adhesions from above. (Plate II,
Fig. 2, e.) The effusion is sometimes great enough to extend
above the brim of the pelvis and even as high as the um-
bilicus.
The uterus is rarely so markedly immobile as in extensive
cellular involvement, though in bad cases it is always more or
less fixed, and may be completely so. The whole pelvic roof
may present a board-like hardness.
Complications.—I have already mentioned that irritation of
the bladder and the rectum is a frequent symptom of pelvic peri-
tonitis and cellulitis. Under the present head it is only
ACUTE PELVIC CELLULITIS AND PERITONITIS.
417
necessary to allude to disturbance of these organs for the
purpose of again reminding the reader that in those cases not
characterized by other decided symptoms of pelvic inflammation
we may find, on examination, an inflammatory exudate respon-
sible for such disturbance. Acute metritis as a complicating
factor has also been dealt with. The remaining conditions to be
considered at this time are acute oöphoritis and salpingitis. In
my treatment of them here I shall comprise all that I have to
say concerning them as distinct acute affections.
Let it be remembered that acute metritis and general pelvic
inflammation are often due to disease of the appendages. Gon-
orrheal salpingitis is a most frequent cause of pelvic peritonitis.
On the other hand, metritis and general pelvic inflammation
rarely if ever run their course without implicating the append-
ages. In perhaps the larger number of cases this occurs
without our being able to determine the fact by any special
symptoms. In reality, then, acute ovaritis and salpingitis occur
as an essential feature of general pelvic inflammation, rather
than as a complication. We may, however, suspect involvement
of the ovary, if pain and tenderness in the region of the affected
organ are marked, particularly if the attacks of pain are attended
with nausea and vomiting. It may be possible by conjoined
manipulation to get the enlarged and tender organ between the
examining fingers; or rectal exploration may reveal the pro-
lapsed and adherent ovary between the uterus and the rectum.
Acute inflammation of the tube is always associated with that of
the ovary.
The sequela of inflammation of these organs are very variable.
If the ovaries are not too seriously damaged, resolution will
ensue upon the subsidence of the general inflammation, or
they may remain imbedded in the inflammatory mass. Suppura-
tion frequently occurs, calling for their removal. The chronic
diseases of the appendages are considered in chapters XLVIII
and XLIX.
Differentiation.-The various forms of acute inflammation of
the pelvis are differentiated, as nearly as it is possible to do so,
in the table of comparison given on page 428. The only con-
27
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A TEXT-BOOK OF GYNECOLOGY.
ditions, therefore, calling for consideration at this time are the
following:-
Pelvic hematocele and extra-uterine gestation;
Uterine fibroids;
Retro-displacements of the uterus;
Carcinomatous infiltration;
Accumulated feces.
Any of the foregoing conditions may lead to confusion when
the resulting tumor resembles that caused by an inflammatory
exudate.
Pelvic hematocele, from whatever cause, gives rise to symptoms
first characterized by shock and collapse. The blood is poured
either into the peritoneal cavity or into the underlying cellular
tissue, thus forming a tumor. The latter, unlike that of cellulitis,
is at first soft, becoming hard after the absorption of serum. If
inflammatory symptoms ensue, they follow those of shock and
collapse.
Extra-uterine gestation is the most frequent cause of pelvic
hematocele. Unfortunately, its existence is often unsuspected
until rupture occurs. There are no pathognomonic symptoms
of this condition. We may suspect it in a patient whose
menstrual function has been disturbed or is absent, if a tumor is
slowly formed in the region of one broad ligament, and is ac-
companied with spasmodic pains in the affected locality. These
symptoms are, however, quite as often absent as otherwise.
Uterine fibroids are attached to the uterus and, if not adhered,
move with it. There is no history of inflammation to account
for their presence. The tumor is painless, and instead of dimin-
ishing as time goes on, it more often slowly increases in size. In
the interstitial and submucous varieties excessive menstruation
is a frequent symptom. In the event of adhesions the differen-
tiation is sometimes extremely difficult.
The unnatural position of the fundus in retro-displacements
of the uterus may give rise to uncertainty as to the nature of the
tumor in the posterior cul-de-sac. This is especially so if the
fundus is bound down by adhesions. Conjoined manipulation
will, in the first place, reveal its absence in front; next, by
ACUTE PELVIC CELLULITIS AND PERITONITIS.
419
passing the sound, the tumor is penetrated, which is not the
case when due to any other cause.
In carcinomatous infiltration there may be slight febrile
symptoms. The disease almost always begins in the cervix,
which will be found indurated and, during the later stages, ulcer-
ated. It is insidious in its development, and in due time cachexia
supervenes.
Accumulated feces ought not to be mistaken for an inflamma-
tory exudate, yet, strangely enough, it more than once has been.
A fecal tumor pits upon pressure. An examination per rectum
will ordinarily suffice to reveal its true character. In all cases
of doubt the colon and rectum should be thoroughly emptied
either by an enema or a cathartic.
Course, Duration, and Sequelae.-No two cases of pelvic
peritonitis and cellulitis run exactly the same course, and the
duration and sequelæ are most variable. We have seen that
pelvic inflammation may exist for an indefinite length of time
without giving rise to serious trouble. This, unfortunately, is
the exception to the general rule, and usually marked pelvic
changes make their presence known in many ways. Pressure
symptoms are of frequent occurrence, the location of the result-
ing pain depending upon the structures impinged upon. If
the great sciatic, the crural, or the external cutaneous nerve is
involved, pain is communicated respectively to the posterior
surface of the thigh, the dorsum of the foot, or the knee. If
the psoas muscle of either side is affected the corresponding
limb is flexed or abducted. It may be many weeks and even
months before the foot can be put to the floor. Involvement of
the bladder and the rectum may continue indefinitely, the
dysuria and tenesmus becoming most distressing. The rectum
is sometimes so distorted as to mold the feces into ribbon-like
bands. Pus may continue to discharge for a long time through
either the bladder or the rectum. Amenorrhea, dysmenorrhea,
or menorrhagia are frequent sequelæ. In some instances the
ovaries are so completely damaged as to destroy entirely their
function and menstruation ceases; in other cases, probably the
larger number, excessive menstruation results. At least my
experience is in keeping with this statement. In removing
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A TEXT-BOOK OF GYNECOLOGY.
appendages damaged by inflammation, menorrhagia has usually
been a prominent indication for the operation. Dysmenorrhea,
due either to continued inflammation, to distortion of the
uterus, or to involvement of the appendages, frequently follows
in the train of the disease. It is not uncommon for inflam-
matory symptoms to recur at each menstrual period-the result,
probably, of an escape of a slight amount of pus at this
time from the Fallopian tubes. Sterility, which is a frequent
sequel, may be due to any of the causes giving rise to disordered
menstruation.
Should pus form, the resulting abscess may rupture in any of
the directions indicated under the head of pathology. After
rupture the abscess may heal and contract, or continue to dis-
charge for an unlimited time, or it may involve the cellular
tissue of the entire pelvis, communicating externally by several
sinuses.
Prognosis. This, in severe attacks, should always be guarded.
Parturient cases are the most dangerous. In forming a prog-
nosis the cause of the inflammation, the vitality of the patient
and her environs, the quantity of effusion, and the presence or
absence of septic symptoms should be noted. If an abscess
forms, this may exhaust the system before healing spontane-
ously. Recovery, so far as life is concerned, is the rule, though
chronic invalidism only too often results.
TREATMENT.
The treatment of the various forms of inflammation included
in this chapter can best be considered under the following
heads:
1. Prophylaxis;
2. Removal of cause if possible after onset;
3. Prevention of effusion of serum;
4. Treatment of symptoms;
5. Absorption and removal of exudates.
Prophylaxis.-The various causes enumerated are to be
avoided. No accoucheur can do his full duty to his patient
without thoroughly mastering the principles of antisepsis. This,
in its broadest sense, implies a full knowledge of those methods.
ACUTE PELVIC CELLULITIS AND PERITONITIS.
421
having for their object the complete emptying of the uterus.
More than this, it implies a familiarity with the evils of pro-
longed labor, for we have seen that septic inflammation oftener
follows in the train of childbirth when the tissues are injured by
long-continued pressure. And last, but not least, it implies.
cleanliness on the part of both patient and physician.
There will be fewer cases of sepsis following delivery when
Credé's method of expressing the placenta is more generally
practised. It is a notorious fact that the average physician has
not mastered, simple as it is, the technique of this method. By
it the uterus is most thoroughly emptied of all débris and clots,
and the danger of leaving portions of the membranes behind is
reduced to a minimum. In early abortions the physician should
not feel at ease so long as any offensive discharge proceeds from
the uterus. Proper rest should always be observed after both
parturition at term and abortion. The patient should not
resume marital relations until involution of all the organs is
complete.
In non-puerperal cases every precaution should be taken in
all operative procedures, no matter how slight, to prevent sepsis.
In the event of chronic uterine and periuterine inflammation
there is always danger of its becoming acute by operating upon
the cervix, or by even introducing the sound. I do not mean to
infer that we should refrain from all operations or examinations
within the vagina because of the existence of sub-acute or
chronic inflammation. I merely wish to caution the student
that, when these conditions prevail, he should proceed with
care, especially at or near the menstrual period.
Removal of Cause. When the inflammation proceeds from
the retention of septic matter within the uterus the indications
are, clearly, to remove it as speedily as possible and to wash
away all shreds and débris with an antiseptic, intra-uterine injec-
tion. If particles of membrane are retained the discharge is usu-
ally offensive and this condition calls for immediate exploration.
The patient should be placed upon her side before a good light,
a Sims speculum introduced, and the cervix gently fixed. The
uterine cavity should now be thoroughly cleared of all septic pro-
ducts by means of a dull wire curette.
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A TEXT-BOOK OF GYNECOLOGY.
Before and after the curetting the cavity should be washed
with a hot bichlorid solution (1-10,000). It must not be used
stronger than this within the uterus, and great gentleness should
be observed. Unless the os is sufficiently large to permit the
water to escape at the side of the tube a reflux catheter is neces-
sary.
After thoroughly douching the parts in the manner described,
the operator should apply over the entire surface of the endo-
metrium either impure carbolic acid or compound tincture of
iodin. I prefer the former unless hemorrhage is troublesome,
in which case the iodin will serve both as a hemostatic and an
antiseptic.
I have more than once seen, after this procedure, the tempera-
ture drop in a few hours from 104° or 105°, to normal. Should
it remain so, it will not be necessary to repeat the intra-uterine
douching. If, on the contrary, it rises again, the douching must
be repeated as often as every four, five, or six hours.
In those instances in which the temperature drops to normal
and remains so, the condition is one of simple septic intoxica-
tion, and the system very quickly eliminates the products of
chemical decomposition which it has absorbed. This is not the
case, however, when the system becomes more profoundly im-
pressed, probably because of the entrance and multiplication of
germs. Here intra-uterine douching may do good, or it may
prove entirely futile. The curette does not always remove all
of the germ-infected tissue, and by persistently using the douche
the germs may be kept from multiplying and entering the or-
ganism; but to accomplish this it must be used at least every
four or six hours. If the temperature be not affected by this
treatment at the end of twenty-four hours, the douching will
probably do no good and may as well be discontinued. The
system, in these cases, is surcharged with the septic poison
already absorbed, to which the persistent high temperature is
due, and which must be contended against by other measures.
Prevention of Effusion of Serum.-A chill followed by fever
and more or less distress in the pelvic region always calls for
complete rest on the part of the patient. She should at once be
placed in bed and kept absolutely quiet. If the case is not of
ACUTE PELVIC CELLULITIS AND PERITONITIS.
423
septic origin, the aim should be to abort the attack and prevent
effusion by measures which, I am firmly convinced, will, if.
faithfully carried out, accomplish the desired end in at least a
goodly percentage of cases. To accomplish this the indicated
remedy, which, in nine cases out of ten, will be either aconite,
belladonna, or veratrum viride, is of first importance. Of almost
equal importance is the use of the hot vaginal douche, as recom-
mended by Emmet. To be of service, however, it must be
used in such a way as to bring into action the thermic proper-
ties of the water. The vaginal douche can be advantageously
supplemented by hot fomentations over the hypogastrium, hot
drinks, etc.
Treatment of Symptoms.-The management of any form of
pelvic inflammation, after it is once inaugurated, requires no little
tact and judgment. Absolute rest can be afforded only by the
coöperation of a skilled nurse who will anticipate and attend to
the patient's every want. The diet should be concentrated and
nourishing, with the judicious use of stimulants added in septic
cases; and the internal remedy should be selected with much
care. Cases of septic origin usually call for one of the following
remedies: Arsenicum, lachesis, bromine, or mercurius.
The bowels should receive due attention. I cannot agree
with some of my confrères that it is a matter of slight impor-
tance whether or not the bowels move in these cases for several
days. Constipation not only aggravates the existing pelvic
inflammation, but, in septic cases, it closes one avenue for the
elimination of the poison. The bowels should, therefore, be
moved at least every other day by enemata of warm water, to
which may be added, in obstinate cases, either ox-gall or gly-
cerin. When the tympanites is great there is nothing more
useful than a saline cathartic. The relief offered by it is often
most decided.
•
Relapses are of frequent occurrence, and the patient should be
kept in bed until the acute symptoms have subsided. There is
always danger in getting up so long as the temperature remains
above the normal or movement causes local pain and distress.
Absorption and Removal of Exudates.-This is often a
most difficult task and may require for its accomplishment a
424
A TEXT-BOOK OF GYNECOLOGY.
long period of time. Until after the subsidence of all acute
symptoms we are compelled to rely almost solely upon the
vaginal douche and the internal remedy. The douche, by over-
coming congestion and stimulating the lymphatics, accomplishes
much good and its value cannot be overestimated. Apis
mellifica is often most useful during this stage.
As the disease becomes more chronic, other measures are of
the greatest utility. The cotton-wool tampon medicated with
boro-glycerid and iodin will promote absorption. The medica-
ments excite a flow of serum, thus relieving congestion, at the
same time stimulating the lymphatics, while the tampon itself
exerts sufficient pressure to hasten absorption.
Galvanism is a therapeutic resource of the greatest value in
the removal of old inflammatory exudates and adhesions within
the pelvis. It is simply astonishing to observe with what rapid-
ity large inflammatory exudates will often melt away under
repeated applications of a current varying from twenty to one
hundred milliampères, supplemented, of course, by the other
measures recommended.
The question of removing encysted serum or pus by opera-
tive measures must necessarily depend upon the conditions that
exist. It may be given as almost an axiom that encysted non-
septic serum, even though large in quantity and easily accessible,
does not require operative interference unless the pressure
induced by it gives rise to unusual suffering. Nature will ordi-
narily care for such an effusion as this. On the other hand, if the
evidences of pus are clearly marked, the circumstances are very
different, and evacuation is, in the larger number of cases, called
for. This may be accomplished when the abscess points into
the vagina either by the aspirator, the trocar, or the bistoury.
The abscess cavity should be washed out and, if the bistoury has
been used, drained.
The operative treatment of pelvic abscess is dealt with in
detail in the chapter devoted to that subject.
Therapeutics.
Aconite.-The early congestive stage with anxious expression of
face; GREAT RESTLESSNESS, High fever, and rapid pulse; burn-
ACUTE PELVIC CELLULITIS AND PERITONITIS.
425
ing, cutting, darting pain in bowels, worse from the slightest
pressure; abdomen hot to the touch; intense thirst.
Veratrum viride.-Great cerebral congestion; violent nausea
and vomiting with cold sweat; heart beats loud and strong with
great arterial excitement; respirations are very slow; face
flushed; pupils dilated; especially useful in the acute stage of
puerperal cellulitis.
Belladonna.-Great congestion of the head; strongly pulsating
carotid arteries; colicky pains in the bowels; great anxiety;
dyspnea; light and noise unbearable; SHOOTING, DARTING,
STABBING PAINS, WHICH COME AND GO IN QUICK SUCCESSION.*
Bryonia.—Stage of exudation; THE LEAST MOTION AGGRA-
·VATES HER SUFFERINGS; her head aches as if it would split open;
stitching, pressing, lancinating pain in the bowels, worse from
slightest motion; tongue white and dry; great thirst; bowels con-
stipated.
Apis.-Stinging, thrusting pain similar to that arising from the
sting of a bee; absence of thirst; urine scanty; dyspnea;
edema of feet.†
Arsenicum.—Sudden sinking of strength; intense internal
restlessness; thirst; constant vomiting; burning in bowels; cold,
clammy perspiration.
Terebinthina.-Excessive distention of the abdomen with weak-
ness and prostration; peritonitis resulting from pelvic hema-
tocele.‡
Gelsemium.—According to Ludlam, this remedy is especially
useful after belladonna, if tardy menstruation is the cause of the
congestion; sharp labor-like pains in uterine region extending
*"The abdomen, in belladonna, is swollen up like a drum and very sensitive to the
touch, so much so that the patient wants all clothing removed."—Farrington. "Uter-
ine congestion is manifested, particularly by a violent stinging, fulness, tension, and urg-
ing deep in the abdomen and the sexual organs, with which there is often conjoined a
dragging, lancinating sensation around the loins "-Hartmann.
+"Apis mellifica is indispensable if pelvic cellutitis complicates the case and if we
desire to abort the tendency to all forms of pelvic abscess.
But it needs to be given in a low form and frequently repeated.”—Ludlam.
"The violent drawing, burning pains in the region of the kidneys, and scanty
and bloody, and often suppressed urine, with distressing strangury, are excellent addi-
tional indications for terebinthina, should they be present."-Southwick.
426
A TEXT-BOOK OF GYNECOLOGY.
to back and hips; pulse at first full and bounding, then feeble
and thready.*
Colocynth.-Violent, cutting, tearing pains, relieved somewhat
by pressure; diarrhea and tenesmus of the rectum; frequent
tenesmus of the bladder with scanty urine; in the acute stage of
pelvic peritonitis with little effusion; pain especially severe in the
left ovarian region.
Cantharis.-Frequent and almost continual desire to urinate,
ineffectual or with cutting, burning pain and passing only a few
drops at a time, which are often mixed with blood; burning in the
uterine region; urinary symptoms are of the greatest importance
in determining upon the selection of this remedy in acute inflam-
mation.
Mercurius cor.-Purulent exudations; creeping chills; foul
breath; vomiting of slime and slimy stool with straining; edema
of feet; weakness and emaciation (Lilienthal)†.
China. Distention and oppression of the abdomen, especially
following great loss of blood; much ringing in the ears; diffi-
cult, but painless urination.
Calcaria carb.-Subacute and chronic cases in leucophlegmatic
constitutions; the feet feel cold and damp; profuse perspiration of
the head and upper part of the body; the history of the case
shows that the menses have been too profuse and return too often.
Hepar sulph.-Particularly indicated to prevent or hasten
suppuration; burning, throbbing pain with chilliness.
Lachesis. This remedy is especially indicated, according to
Guernsey, in pelvic inflammation occurring at the critical age;
exacerbation of the soreness after every sleep whether by day
or by night; extreme sensitiveness to pressure; cannot even toler-
ate the clothes upon the uterine region. ‡
* "The pulse rises, in gelsemium, during the reaction after the chill as far above the
normal as it has been below it.”—T. F. Allen.
•
•
+"Inflammation of the peritoneum and effusion into this sac is a frequent feature
in poisoning by corrosive sublimate .
I have myself the highest
esteem for this remedy in peritonitis. I have used it here more frequently than
bryonia and with more gratifying results." —Hughes.
"In peritonitis lachesis is indicated when the fever still continues and is worse
after I P. M. and at night. The slightest touch to the surface of the body is intoler-
able.” — Farrington.
ACUTE PELVIC CELLULITIS AND PERITONITIS.
427
•
Phosphoric acid.-Great distention of the abdomen with
marked debility and great indifference to all about her; low
fever.
Rhus tox.-Puerperal cases worse at night, especially after
midnight; restlessness; changing the position affords temporary
relief; powerlessness of the lower limbs, she can hardly draw
them up; low fever with dry tongue.
Hyoscyamus.-Spasmodic symptoms with jerking of the
extremities, face, and eyelids; emotional disturbances; typhoid
state with delirium; the patient throws off the bedclothes.
Iodium.-Implication of mammæ, which become very sore;
there is a low cachectic state of the system with feeble pulse.
Sulphur.-Weak, faint spells with frequent flushes of heat;
papillary eruptions over the body.
Sabina. Metritis following menorrhagia or metrorrhagia of
clotted and fluid blood, with pain from sacrum or lumbar region
to pubes.
Silicea.-Constant chilliness followed by fever with violent
heat in the head, worse at night; especially useful after suppura-
tion with fistulous openings which discharge a large amount of thin,
unhealthy pus; profuse, sour, or offensive perspiration at night;
headache and nervous symptoms resulting from loss of strength;
great constipation; constant and ineffectual desire for stool.
Cimicifuga.-Rheumatic women subject to pleurodynia, rheuma-
tism, etc.; LUMBAGO; pain and distress in the pelvis with scanty
or irregular menstruation; despondency; subacute pelvic peri-
tonitis in rheumatic women.
Opium.--Cases resulting from fright; flushed face; delirium;
soporousness; sleepy but cannot sleep; constant vomiting and
belching; complete inactivity of the lower bowel.
Arnica.-Pelvic inflammation from traumatism.
Consult :-Stramonium, secale, sepia, platina, pulsatilla, kali
carb., and conium mac.
TABLE COMPARING ACUTE INFLAMMATION OF THE VAGINA, UTERUS AND ANNEXA, AND PERI-UTERINE TISSUES.
VAGINITIS.
Most frequent cause is gonor-
rheal infection; difficult to
differentiate specific from non-
specific form.
Intensity of onset depends upon
acuity of symptoms; usually
slight chill or chilliness.
Febrile symptoms slight.
METRITIS AND ENDOMETRITIS.
Most frequent cause is sepsis
connected with abortion or
parturition.
In light, non-puerperal cases the
initiatory symptoms at onset
no more marked than in vagi-
nitis; in puerperal cases de-
cided chill.
Febrile symptoms usually slight
in uncomplicated non-septic
cases; marked in septic cases.
PERITONITIS.
When primary, most frequent cause is
extension of inflammation from uterus
or tubes; imprudence during menstru-
ation; gonorrheal extension.
Initiatory chill not marked.
Febrile symptoms depend upon cause
and extent of tissue involved; usually
marked, and the pulse is small and
wiry.
Absence of inflammatory tumor; Absence of inflammatory tumor. Formation of tumor,which is oftener loca-
vagina first dry and hot, and
then becomes bathed in pus
or muco-pus.
Thighs not retracted.
Thighs not retracted.
movable.
ted posteriorly or anteriorly; if lateral,
usually high up; does not bulge into
fornix; hardening of pelvic roof.
Retraction of both thighs.
Uterus is movable, and not in Uterus is increased in size, and Uterus but slightly movable, and often
creased in size.
fixed; displaced in any direction, de-
pending upon location of effusion.
CELLULITIS.
Where primary, most frequent cause is
connected with operations upon uterus;
parturition and abortion.
Initiatory chill marked.
Febrile symptoms depend upon cause
and extent of tissue involved; usually
marked, and the pulse is full and
bounding.
Formation of tumor, which is oftener
lateral; at first soft and doughy, then
hard, becoming soft again if pus forms.
Retraction of one thigh.
Uterus more movable than in peritonitis;
usually displaced laterally.
Pain of a burning character Pain indefinite; augmented by More painful than in cellulitis, and some- Pain depends upon pressure.
and low down.
moving uterus.
No vomiting.
times pain is very great.
No vomiting if uncomplicated.
Vomiting often marked; worse if ovaries Vomiting not so marked.
are involved.
428
CHAPTER XXIX.
CHRONIC ENDOMETRITIS (CERVICAL AND COR-
POREAL); CHRONIC METRITIS (SUBINVO-
LUTION; HYPERTROPHY; AREOLAR
HYPERPLASIA).
For reasons similar to those given in the preceding chapter I
deem it entirely logical to include in one chapter the several
chronic inflammatory affections of the uterus. They all possess
symptoms in common, and the principles of treatment observed in
all are much more alike than is the case in the treatment of acute
and chronic inflammation of any of the tissues of the uterus. This
classification is, therefore, infinitely less confusing to the student
than the older one in which the various acute and chronic diseases
of the organ are considered seriatim. Then, too, the pathological
changes justify the classification adopted, for there is at least an
insensible shading of the various forms of chronic inflammation
into one another, and, oftentimes, the blending is very distinct.
Chronic cervical endometritis, and granular and cystic degeneration
of the cervix, represent, in reality, but different stages of one
and the same disease. The general symptoms are practically
the same in all, and they can be differentiated the one from the
other only by physical examination. So-called fungoid degenera-
tion of the endometrium likewise represents but a form of corporeal
endometritis and should be so dealt with. Again, subinvolution
of the uterus, hypertrophy, and areolar hyperplasia are but stages
of chronic metritis (although areolar hyperplasia occasionally oc-
curs in nulliparous uteri), and are therefore included under
that head.
CHRONIC CERVICAL ENDOMETRITIS AND GRANULAR AND
CYSTIC DEGENERATION OF THE CERVIX.
Definition. By the term chronic cervical endometritis is
meant an inflammation, chronic in character, of the cervical mu-
429

430
A TEXT-BOOK OF GYNECOLOGY.
cous membrane, which extends from the os externum to the os
internum. It is the most frequent of all gynecological diseases,
and is also known as endo-cervicitis, cervical catarrh, etc.
Anatomy.-The surface of the cervical mucous membrane is
greatly increased by the so-called arbor vitæ, which are nothing
more than folds or ridges of mucous membrane studded with
numerous villi and covered with cylindrical and pavement epi-
thelium. Large numbers of muciparous glands, known as the
follicles of Naboth, are between these folds. It is estimated that
in a well-developed virgin cervix there are at least 10,000 Na-
FIG. 70.
FIG. 71.
LACERATION WITH EROSION OF THE
CERVIX. (Martin.)
EROSION WITH ENLARGEMENT
OF FOLLICLES. (Martin.)
bothian follicles, and it is from them that the alkaline cervical se-
cretion is derived.
Pathology. The first step in cervical endometritis is hy-
peremia of the Nabothian follicles. They become engorged and
elevated, with dilated mouths, which are filled with a secre-
tion which is at first alkaline and viscid, like the white of an egg;
later it becomes more adhesive and tenacious, being loaded with
epithelial cells; finally, it becomes muco-purulent and sometimes
tinged with blood. It also becomes exceedingly acrid, disinte-

CHRONIC CERVICAL ENDOMETRITIS.
431
grating the epithelial layers of mucous membrane, which leaves
the underlying surface exposed (Fig. 71). This is known as
abrasion or erosion, and while in the strictest sense of the term it
is a form of ulceration, it is too superficial in character to fall
properly into that classification. If the disease is arrested at this
point the epithelium is restored and the redness disappears. If,
instead, it progresses, the mucous membrane proper becomes im-
plicated and the papillæ undergo proliferative changes and pro-
ject in the form of granules through the abraded tissue. This
constitutes granular degeneration (Fig. 72). † Since the papillæ
are richly supplied with blood-vessels, the older works describe
this condition as "bleeding ulcer" or "cock's-comb granulation."
FIG. 72.
FISSURED CERVIX WITH GRANULAR MUCOUS MEMBRANE. (Schroeder.)
The granulations sometimes increase in size and number until
they form a large mass.
The hypertrophy of the mucous membrane which attends the
disease creates a tenesmus which may give rise, even in virgins,
to great eversion. The os externum becomes patulous and the
cervical canal greatly distorted. The manner in which this
eversion is produced is shown in Fig. 73.
If the inflammation is localized in the muciparous follicles it
causes the latter to become greatly distended, and finally to
burst, thus giving rise to so-called follicular ulceration. Exten-
* Dunglison defines an ulcer as a solution of continuity of the soft parts. Accord-
ing to the later researches of Ruge and Veit, the epithelium is not entirely destroyed in
this condition.
+Ruge and Veit say that these villous projections are not hypertrophied papillæ, but
new formations.

432
A TEXT-BOOK OF GYNECOLOGY.
sive involvement of these follicles constitutes cystic degeneration
FIG. 73-
b
a
d
ECTROPION OF THE CERVIX.
The cervical mucous membrane is hypertrophied as a result of the inflammation and,
because of the tenesmus excited, is forced from the cervical canal: (a) represents
the normal state and (b), (c) and (d) the successive degrees of ectropion.
(Auvard and Devy.)
FIG. 74.
LACERATION OF THE CERVIX, WITH CYSTIC AND PAPILLARY HYPERPLASIA, SIM-
ULATING EPITHELIAL CANCER. (Munde.)
of the cervix (Fig. 74.) Instead of the extensive changes here
CHRONIC CERVICAL ENDOMETRITIS.
433
shown the enlarged Nabothian glands may assume the shape of
polypi.
The foregoing changes indicate the several pathological steps
leading from simple catarrhal inflammation of the cervical
endometrium to extensive granular and cystic degeneration and
ulceration. True inflammatory ulceration is very rarely met
with. As already indicated, simple catarrhal inflammation is of
most frequent occurrence; granular degeneration also occurs
with great frequency; while cystic degeneration, though by no
means rare, is much more so than the affection last named. In
many cases, however, the only evidence of simple endocer-
vicitis will be an unnatural discharge proceeding from the cervix.
Etiology. The causes are both predisposing and exciting.
Under the first head may be included:-
The various dyscrasiæ, as scrofulosis, tuberculosis, etc.;
Want of fresh air and exercise;
Ill-nourishment;
Improper dress;
Subinvolution.
The exciting causes are:—
Cervical lacerations;
Extension of vaginitis;
Excessive coitus;
Prevention of conception;
Undue exposure, especially during menstruation ;
Frequent parturition;
Excessive lactation;
Intra-uterine stem pessaries.
Of these several causes, the various dyscrasia are perhaps
the most important. Women of lymphatic temperament, especi-
ally blondes, are particularly liable to cervical inflammation; in
these subjects there is a peculiar tendency to catarrh of all the
mucous membranes of the body. Endocervicitis in this class of
patients is usually most obstinate.
Cervical catarrh is almost always a complication of subinvolu-
tion, and it is frequently associated with corporeal endometritis.
Of the exciting causes cervical lacerations are to be ranked of
first importance. The laceration, with consequent eversion, ex-
28
434
A TEXT-BOOK OF GYNECOLOGY.
poses the lower part of the mucous membrane to friction against
the vaginal walls and to irritation during coitus. The various
means resorted to for the prevention of conception frequently give
rise to cervical catarrh as well as to general pelvic congestion.
Cold vaginal injections immediately after intercourse, when all
of the sexual organs are unduly flushed with blood, is a most
pernicious practice, though but little worse than the use of con-
doms, or the practice of withdrawal of the male organ immedi-
ately before ejaculation. In fact, any cause that tends to
keep up a congestion of the uterus and the pelvic organs is
liable in time to induce cervical catarrh, especially in one
predisposed to inflammation of the mucous membranes.
Symptoms.-The symptomatology depends more upon the type
of constitution met with in a given case than upon the extent of
the disease. It is a most common thing for the physician to
meet with cases of cervical endometritis in which the local evi-
dences of the disease are most marked, though the general
symptoms may be entirely wanting; whereas, in other cases
with but slight disease, the general symptoms are most distress-
ing. Some temperaments are much more profoundly affected
than others by any lesion, and as regards those of the uterus
this is pre-eminently so.
Leucorrhea is the most common symptom, and may be the
only one attracting the patient's attention. The discharge is at
first thick, viscid and albuminous, but as the disease progresses,
and especially if villous erosions exist, it becomes muco-puru-
lent and not infrequently tinged with blood.
In time other symptoms of a more general character may de-
velop. The patient complains of an ill-defined, dragging sensa-
tion in the pelvis which is made worse when she is on her feet
for any length of time. Pain in the back, which is almost
.always aggravated at the menstrual period, is of very common
occurrence. The stomach is frequently implicated in a reflex
way, so that the nutrition becomes impaired and nervous symp-
toms develop. Melancholia, occipital and vertical headache,
neuralgia in various parts of the body, and hysterical manifesta-
tions may follow in the train of mal-nutrition.
Disordered menstruation likewise frequently attends endocervi-
CHRONIC CERVICAL ENDOMETRITIS.
435
citis. Dysmenorrhea occurs oftener than menorrhagia, though
if the corporeal endometrium is also involved, the latter condi-
tion may be the most prominent. Pain upon sexual intercourse
rarely results unless there exist cervical hyperplasia with the
catarrhal condition. In granular and follicular degeneration
there may be hemorrhage following intercourse. Other symp-
toms, such as constipation, disordered micturition, etc., are not
infrequent.
Physical Signs.-The extent of the disease can only be
determined by local examination. Digital exploration alone is,
however, many times uncertain, for should the os not be patulous
the finger may not detect anything wrong.
The speculum will more accurately determine the exact patho-
logical changes. The parts are frequently concealed by the un-
natural discharge which is present. By carefully removing this
the cervical tissue will be exposed. In simple catarrhal inflam-
mation the slight discharge hanging from the cervix may be the
only evidence of disease; or the os may be patulous and the
mucous membrane everted and congested; or there may be
granular or cystic degeneration as shown in Figs. 72 and 74.
If the patient has borne children lacerations are usually found
and the eversion is often great. I have even seen the eversion
in virgins so great as to cause me strongly to suspect for the
time the chastity of the patient. This is not of uncommon
occurrence, especially if the disease is associated with cel-
lulitis, and I strongly emphasize the fact because the condi-
tion frequently gives rise to unjust suspicion. A correct decision
is so important that I quote in detail the following case from
Emmet: *
During the spring of 1880 I was consulted by a young, unmarried girl whom I
had seen grow up from a child, and whose character was above reproach. I first
made a rectal examination with my finger, with the object of avoiding a vaginal one,
if the needed information could be obtained. I detected an extensive cellulitis behind
the uterus and to the left, but was unable to recognize the exact condition of the
uterus, as a mass, very tender on pressure, was felt, which seemed too large for the
cervix and not large enough for the uterus. I was surprised to find that this mass
was the cervix greatly enlarged in proportion to the size of the uterine body, and that
it had the characteristic feel of a laceration. I introduced the speculum, and, to my
* " Principles and Practice of Gynecology," 1884, p. 460.
436
A TEXT-BOOK OF GYNECOLOGY.
sorrow, I saw the mucous membrane of the canal everted apparently to the internal
OS. If I had been placed on the witness stand I could have conscientiously taken an
oath that a criminal abortion had been recently performed. As the poor girl got up
from the chair the expression of her face was so indicative of all that was pure and
innocent that I could ask no questions. During the whole course of my professional
life I never watched the progress of another case with such interest. The cellulitis
yielded to treatment with unusual rapidity, and to my gratification the everted surfaces
rolled in again as the inflammation lessened; the cellulitis at the end of three months
had all cleared up and nothing but a virgin os remained."
When in doubt, in a case like that recorded by the eminent
specialist just quoted, the only absolute test is time and proper
treatment. In virgins the parts will ultimately regain their normal
appearance; whereas, if lacerations exist, the rents are only made.
more prominent by curing the inflammation and hyperplasia.
Differentiation.-Chronic cervical endometritis can be posi-
tively differentiated from vaginitis only by a specular examina-
tion. It is a frequent complication of chronic vaginitis. The
symptoms which distinguish it from chronic corporeal endometritis
are given in the section devoted to the last-named disease.
There is some danger of confounding granular and cystic de-
generation, particularly if hyperplasia and lacerations exist, with
epithelioma.
The induration in epithelioma is much more marked; there is
a peculiar hardness about the os; hemorrhage is more easily
excited; and the mucous membrane is attached to the subjacent
structures. Every now and then cases will be met with where
the uncertainty is very great and a section may have to be
removed for microscopic examination. Proper treatment rapidly
reduces simple hyperplasia with degeneration, which is not the
case if the disease be malignant.
In the event of ulceration we should determine whether or
not the destruction of tissue is due to syphilis. Syphilitic ulcer-
ation of the cervix is not a common affection. It will be recog-
nized by its yellow, opaque color; by its precipitous borders
and depressed surface; and by the rapid development of con-
stitutional symptoms.
Prognosis. When left unmolested it may continue indefi-
nitely, becoming worse and worse as time goes on.
treatment will have to be persevered in for weeks, or
While
even
CHRONIC CORPOREAL ENDOMETRITIS.
437
months in cases of long duration, a cure can usually be accom-
plished in the end.
CHRONIC CORPOREAL ENDOMETRITIS AND UTERINE FUNGOSITIES.
The endometrium of the body of the uterus, like that of the
cervix, may be the seat of chronic inflammation. When
so affected it has been described under the names of chronic
corporeal endometritis, internal metritis, uterine leucorrhea,
uterine catarrh, etc.
As regards its frequency, corporeal endometritis does not
occur nearly so often as does cervical endometritis. So good an
authority as the late Prof. Byford of Chicago, makes this asser-
tion:* "Inflammation limited to the cavity of the body of the
uterus is not common, but I am quite sure that I have met with at
least two instances." This to me is a most surprising statement to
come from one of Prof. Byford's experience, for I am sure that I
have many times met with chronic inflammation limited to the
corporeal endometrium, or at least not involving the mucous
membrane of the cervix. In by far the larger number of cases,
however, it occurs in connection with cervical endometritis.
Anatomy.-The mucous membrane of the fundus, like that
of the cervix, is studded with numberless follicles which are
lined with delicate ciliated epithelium, and open into the uterine
cavity much as the glands of Lieberkühn open into the intestines.
These follicles are long and curling, their closed extremities pro-
jecting toward and into the uterine parenchyma, between which
and the fundal endometrium there is no areolar tissue. Numer-
ous capillaries form a network about their mouths, projecting
like villi into them and ramifying between them. They exist in
the form of simple and compound glands: the first are un-
branched tubes; the second possess several branches.
Pathology. As in acute endometritis, the underlying muscular
structure is always more or less involved, though the two affec-
tions (chronic metritis and endometritis) are sufficiently distinct
to warrant separate consideration.
The follicles described are the chief seat of the disease, which
*" Medical and Surgical Treatment of Women," page 182.
438
A TEXT-BOOK OF GYNECOLOGY.
accounts for the exaggerated discharge. The secretion is not only
increased, but altered in quality. It is alkaline and thin during
the early stage, but in time becomes rust-like and muco-
purulent.
The changes in the mucous membrane are most variable. In
cases of short duration it is merely swollen and congested.
Later on granulations may form not unlike those in cervical
endometritis. In the more severe cases partial exfoliation of the
mucous membrane occurs, and villous proliferations spring up
from the subjacent tissue, owing to exaggerated local nutrition.
This last condition constitutes the so-called villous fungosities
or fungoid degeneration of the endometrium. As time pro-
gresses large numbers of the follicles are obliterated and the
mucous membrane atrophies; or the openings of the follicles
only are obliterated, resulting in distention from the retained
secretions. It is claimed by some pathologists that, in cases of
long standing, a thin layer of connective tissue, covered by pave-
ment instead of cylindrical or ciliated epithelium, replaces the
mucous membrane.
Causation.-Many of the causes giving rise to cervical en-
dometritis may, under favorable conditions, excite fundal endo-
metritis, as well. It is only necessary to enumerate, in the
disease now under consideration, the following:-
Extension of vaginitis and cervicitis;
Parturition and abortion;
Retention of menstrual discharge;
Membranous dysmenorrhea;
Injury resulting from the sound, intra-uterine pessaries, etc. ;
Exposure during menstruation.
Extension of vaginitis and cervicitis to the corporeal endome-
trium is of common occurrence, a fact emphasized in dealing
with acute endometritis. It is the specific form of vaginitis
which is most liable to extend to the endometrium.
Parturition and abortion are not infrequently followed by
endometritis because of mechanical injury, or because of some
of the products of conception being left behind. In criminal
abortion the unskillful use of the sound is very apt to lacerate
the endometrium in such a way as to set up inflammation.
CHRONIC CORPOREAL ENDOMETRITIS.
439
Probably the most important and frequent cause of corporeal
endometritis is the retention of menstrual discharge because of
some obstruction to its exit. Whatever the nature of the
obstruction, the retained blood becomes deteriorated and clotted.
This irritates the mucous membrane, giving rise to uterine
contractions, and endometritis.
The pathology of membranous dysmenorrhea is so uncertain
as to make it difficult to determine in a given case whether this
affection is the result or the cause of the endometritis. At any
rate, more or less endometritis is always associated with this
form of painful menstruation.
I have in another place dwelt upon the danger of permitting
patients to wear the intra-uterine stem while up and about.
When these pessaries were more fashionable than now endome-
tritis was more common. I never use them except after divul-
sion, and always keep the patient in bed until the stem is
removed.
The careless and indiscriminate use of the uterine sound in the
non-pregnant is sometimes responsible for an acute endometritis
which may become chronic. If the sound be intelligently used
and is clean, there is, however, but little danger of inflammation
attending its introduction. This, of course, implies proper ob-
servance of the counter indications.
Menstrual suppression from exposure always gives rise to more
or less congestion of the endometrium, which may, as time goes
on, develop into a chronic catarrh. As is well known, acute en-
dometritis from whatever cause frequently ends in chronic
inflammation.
Symptoms.-These, as in endocervicitis, are remarkable for
their variableness. In many cases corporeal endometritis of the
most decided nature exists indefinitely without giving rise to
any trouble other than a leucorrheal discharge. In most
instances, however, the general symptoms are sufficiently
marked to attract attention to the uterus, though it cannot be
said that they are pathognomonic.
The most constant symptom is leucorrhea. The discharge is
not nearly so tenacious as that from the cervix, though when the
cervical endometrium is also involved there is a commingling of
440
A TEXT-BOOK OF GYNECOLOGY.
the discharge from both sources. It may be either serous,
muco-serous, or muco-purulent in character; or of a brownish,
rust-colored tint. The last named quality is very characteristic,
though a similar discharge may occur in any disease of the
uterus in which there is a slight loss of blood.
In the worst cases the discharge consists of almost pure pus.
Again in some forms of senile endometritis it is decidedly
watery and, when retained, gives rise to that condition known
as hydrometra. In cases of long standing it is often most exco-
riating, setting up intense pruritus vulvæ.
The symptom which in point of frequency comes next is
disordered menstruation. The disease is neary always attended
by either menorrhagia, dysmenorrhea, or amenorrhea.
The menorrhagia is due to hypertrophy of the mucous
membrane, and in fungoid degeneration the loss of blood is
usually very great. As soon as the connective tissue becomes
affected pain is associated with the menorrhagia. Pain also
characterizes exfoliation of the endometrium. In atrophy of
the mucous membrane the menstrual discharge is lessened in
quantity and may cease entirely.
Sterility is a frequent, though by no means inevitable,
symptom. I have certainly met with cases presenting all the
evidences of chronic corporeal endometritis in which conception
occurred. If the mucous membrane is much diseased, however,
the woman can hardly conceive, for the unnatural discharge is
inimical to the life of both the spermatozoa and the ovum.
Pain in some form is rarely absent. It is not in any sense
pathognomonic, for it is such as may result from any of the
chronic inflammatory affections of the uterus. Patients often
speak of it as being of a dragging character, and not infrequently
it extends down the inner surface of the thighs. It is always
made worse by any physical exercise requiring the patient
to be on her feet for any length of time. Deep pressure over the
hypogastric region will sometimes reveal tenderness of the
uterus. There is often a throbbing, burning sensation in the
supra-pubic region. The uterus is more or less tender on bi-
manual examination, but not nearly so much so as when the
disease involves chiefly the muscular structure of the organ.
CHRONIC CORPOREAL ENDOMETRITIS.
44I
The bowels are usually inactive, and the superadded constipation
tends to aggravate the uterine congestion. The urinary function
is likewise frequently implicated, the urinary secretion itself pre-
senting all of the varying characteristics of so-called "hysterical
urine."
As the disease progresses the nutrition sometimes becomes
markedly affected. The appetite is impaired, there is often
nausea with vomiting, and, if flatulency accompanies these
symptoms, as it frequently does, pregnancy may be suspected.
There is, too, as in pregnancy, a peculiar tendency to pigmentation
of the skin, especially on the forehead and abdomen and around
the nipples, which adds to the uncertainty of diagnosis. The
pigmentary deposits on the face, together with the emaciation
and the dark areolæ around the eyes, give to the patient a
peculiar expression to which the name facies uterina has been
applied.
Any or all of the nervous phenomena mentioned under the
Hystero-neuroses not infrequently occur. Hysteria, melancholia,
neuralgia in any and every part of the body, and even hystero-
epilepsy, may develop. Headache is probably the most frequent
reflex pain, and it is located, in at least the larger number of
cases, at the vertex. Pain in the right hypochondriac region
is not an uncommon symptom of chronic endometritis.
Physical Signs.-The tenderness of the uterus on conjoined
manipulation, the pain arising from passing the uterine probe, the
slightly increased length of the uterine cavity, and the character-
istic discharge which has been described, are practically all of the
physical signs affording any positive information in making a
diagnosis. A leucorrhea issuing from the cervix, with absence
of discernible cervical disease, is pretty conclusive evidence that
it proceeds from the fundus. The only exception to this
statement would occur in cases of pyosalpinx drained through
the uterus. There is, too, especially in fungoid endometritis,
a peculiar tendency to hemorrhage after the introduction of the
probe.
Differentiation.-The physical signs enumerated will ordin-
arily enable the physician to distinguish chronic corporeal endo-
metritis, when uncomplicated, from cervical endometritis. When
442
A TEXT-BOOK OF GYNECOLOGY.
the two affections exist conjointly it may be difficult to determine
that the fundal endometrium is involved. A symptom of some
value is the patulousness of the internal os, which nearly always
exists when the fundus is implicated.
Care should be taken to determine pregnancy when this con-
dition is suspected.
*
Prognosis.—Under the most favorable circumstances, and with
all the resources of gynecic art, chronic corporeal endometritis
is an exceedingly obstinate affection. Scanzoni affirms that he
has never been able to cure a case of several years' duration, and
all writers agree that the prognosis, in diseases of long standing,
is most sinister. So much depends upon the coöperation of the
patient that, without such coöperation, little can be accomplished.
If this can be secured I think that the ordinary cases can be not
only greatly relieved, but eventually cured. I speak with much
more confidence since adding to my armamentarium proper appa-
ratus for the intelligent use of intra-uterine galvanism. The most
obstinate cases are those of long duration with much enfeeble-
ment of the constitution and with bad retro-displacement of the
uterus. Proper drainage of the organ, which is all-important, is
difficult when flexion exists, and profoundly debilitated patients
are usually unable to tolerate measures having for their object
the correction of the displacement.
CHRONIC METRITIS (SUBINVOLUTION; HYPERTROPHY; AND
AREOLAR HYPERPLASIA OF THE UTERUS).
General Considerations and Pathology.-Not infrequently
the uterus is found upon local examination to be hard, dense,
sensitive, and increased in size. This condition is oftener met
with in women who have borne children, or who have had one
or more miscarriages. For years the peculiar and marked
changes giving rise to this unnatural state were supposed to be
the result of a chronic parenchymatous inflammation, and the
various text-books dealt with it under the name of CHRONIC
METRITIS. Some years ago Prof. T. Gaillard Thomas, drawing
his deductions from the pathological findings of Klob, Scanzoni,
"Diseases of Females," Am. Ed., p. 202.
CHRONIC METRITIS.
443
and others, became convinced that chronic inflammation had
but little to do in bringing about this peculiar state of the organ.
He sums up his conclusions as follows:
*
“I. The condition ordinarily styled chronic metritis consists in
enlargement due to hypergenesis of tissue, especially of its con-
nective tissue, which induces nervous irritability and is accom-
panied by congestion.
“2. Decidedly the most frequent source of this state is inter-
ference with involution of the puerperal uterus. A very large
proportion of the cases of so-called parenchymatous metritis are
really later stages of subinvolution.
"3. Areolar hyperplasia is often induced in a uterus which
has once undergone the development of pregnancy by displace-
ment, endometritis, and other conditions, including persistent
hyperemia.
‘4. The same influences may possibly induce it in a nulliparous
uterus, most frequently they do so in the neck, but such a result
is exceedingly infrequent.
"5. However produced, the condition is one of vice of nutri-
tion, engendering hyperplasia of the connective tissue as its
most striking feature, and, although attended by many signs and
symptoms of inflammation, it in no way partakes of the character
of that process."
Thomas therefore teaches that the term chronic metritis is a
misnomer and should be discarded, and that the actual con-
dition brought about by the causes enumerated, the most frequent
of which being arrested puerperal involution, is hyperplasia rather
than hypertrophy of the uterus. He has accordingly proposed
the term areolar hyperplasia as one more clearly defining the
actual pathological changes which the tissues of the uterus
undergo. To him the profession is much indebted for his able
and scholarly writings upon the subject.
If it be true, as Thomas affirms, that by far "the most frequent
cause of this state is interference with involution of the puer-
peral uterus," then subinvolution is but the first stage of areolar
* Thomas and Mundé, " Diseases of Women " page 316, 1891.
† By hypertrophy is meant excessive growth of the elements of tissue already ex-
isting; by hyperplasia, the development of new tissue. (Virchow.)
444
A TEXT-BOOK OF GYNECOLOGY.
!
hyperplasia (so-called chronic metritis), and should be so con-
sidered; and while hyperplasia is undoubtedly the final step in
the pathological process which leads up to it, I think that there
is clearly an intermediate stage, which is more correctly de-
fined, according to the definition of Virchow, by the term hyper-
trophy. In proof of this I quote the observations of Finn made
at the Institute of Pathological Anatomy in St. Petersburg.*
"I. The normal disposition of the single muscular fiber, as well
as of the muscular bundle, remains unchanged.
“2. The muscular fibers do not change in quality, neither is
there fatty degeneration as a pathognomonic sign of the disease.
"3. The muscular fibers are always extended in both their
length and breadth above their normal standard, but more so in
the former direction.
"4. The number of fibers is always largely increased.
5. The amount of connective tissue in the latter stage of the
disease is always relatively diminished, but absolutely enlarged,
so that the increase of bulk of the uterus is mainly caused by the
hyperplasia of the muscular fibers, the augmentation of the con-
nective tissue influencing it but little.”
Klob, on the other hand, says: "The whole uterine connective
tissue sometimes proliferates, either without accompanying in-
crease of the muscular substance, or, if this does occur, the con-
nective tissue predominates to such an extent that the muscular
substance is comparatively of not much account." +
It is probable, as suggested by Thomas, that Finn made his
examinations during the early stages of subinvolution, whereas
the uteri examined by Klob were those in which the changes had
existed for a long time. In this way only is it possible to
reconcile the statements made by pathologists equally dis-
tinguished. It seems very strange indeed that later researches
bearing upon the subject have not been made. Surely, the dead
room furnishes material in abundance, and it is a question which
ought not to be difficult to clear up.
Are we justified, then, from the data given, in entirely elimi-
nating inflammation as a causative factor in the production of the
* American Journal of Obstetrics, Vol. 1, p. 264.
+ Thomas and Mundé, op. cit., p. 310
CHRONIC METRITIS.
445
affection under consideration, which has for its beginning hyper-
trophy of tissue and for its ending hyperplasia? I think not. I
have elsewhere shown* that three forms of hyperemia are met
with viz: active hypertrophic; passive venous or congestive; and
inflammatory. The first gives rise to hypertrophy, because of
exaggerated local nutrition; in the second and third there is
thrown out a fibrino-plastic effusion, which contracts, cuts off the
capillary circulation of the parts involved, and becomes organized
into a low form of connective tissue. As a result the connec-
tive tissue is not only increased from this source, but the
resulting irritation gives rise to hypergenesis of that already
existing, and in time the muscular structure is largely sup-
planted by it. Now, if these views are based upon sound
premises, it is not only possible, but exceedingly probable, that
acute metritis, after producing the changes described, will merge
into a low form of chronic inflammation which may continue in-
definitely; and while granting that uteri which have undergone
the development of pregnancy are infinitely more liable to take
on the changes ending in so-called areolar hyperplasia, I do
not believe that nulliparous uteri, the seat of chronic endometri-
tis, are exempt from it. That in the vast majority of instances
the starting point is subinvolution no one will deny; but let it be
remembered that one of the most frequent causes of subinvolu-
tion is inflammation, either of the endometrium, the parenchyma,
or both; and if we admit the existence of chronic corporeal en-
dometritis—and most authorities are agreed that this is not an
uncommon affection-we must also admit the frequent involve-
ment, to a greater or less extent, of the uterine parenchyma, due
to the peculiar anatomy of the parts. If this be true, it seems to
me that such inflammation may not only be the primary cause of
the hyperplasia, but it may persist as a feature of it.
To recapitulate, then, the pathological changes, as I understand
them, occur as follows
When following parturition or abortion :-
I. The existing hypertrophy of both the muscular structures
and connective tissue persists for a certain length of time, owing
to arrested involution.
* v. page 120.
446
A TEXT-BOOK OF GYNECOLOGY.
2. Hypergenesis of the connective tissue, owing to irritation or
exaggerated local nutrition, ensues; or, if the subinvoluted
uterus is inflamed, a fibrino-plastic effusion is thrown out, which
becomes organized.
3. Then follows condensation of the connective tissue thus
formed, which contracts and cuts off the capillary circulation,
the whole organ becoming hard, dense, and sensitive.
When occurring in the non-puerperal :-
1. If from any cause (displacement, excessive coition, obstructed
pelvic circulation, etc.) persistent hyperemia is engendered, there
results hypertrophy of the uterus because of exaggerated local
nutrition. Hypergenesis of the connective tissue is probably in
excess of that of the muscular structure.
2. If, on the other hand, the hyperemia be due to inflamma-
tion, there is poured into the parenchyma of the organ a fibrino-
plastic effusion. This in time, as in the puerperal uterus, becomes
a low type of connective tissue, which, added to that resulting
from the exaggerated nutrition incident to the inflammatory
hyperemia, causes a preponderance of this tissue over the
muscular. Secondary contraction and condensation does not
differ from that following parturition.
Causation. As will be gleaned from a review of the pathology,
any condition, state, or cause tending to keep up a persistent
hyperemia of the uterus, either because of direct irritation or by
interfering with the return of blood from this organ, is liable in
time to induce areolar hyperplasia. Such are:—
Arrested puerperal involution ;
Excessive sexual indulgence;
Cardiac, hepatic, pulmonary, and lung disease;
Uterine displacements;
Neoplasms and abdominal tumors;
Habitual constipation;
Chlorosis, anemia, or malnutrition from any cause;
Ungratified sexual desire;
Prevention of conception.
In order fully to appreciate the importance of arrested puerperal
involution it is necessary to revert to the physiology of the most re-
markable, and, to me, most interesting process of normal involution.
CHRONIC METRITIS.
447
A normal nulliparous uterus measures in length, from the
external os to the peritoneal investment of the fundus, three
inches. In the short space of nine months this diameter is
increased to nearly fifteen inches, the transverse to ten inches,
and the antero-posterior to nine and one-half inches. Or perhaps
the increase will be more easily appreciated by stating that the
area is increased from sixteen square inches to three hundred
and thirty-nine square inches (Levret), and that the weight is
increased from a little more than an ounce to twenty-eight
ounces. By the processes of involution a uterus of this size
should return in from six to eight weeks nearly to its normal
size.
Retrograde metamorphosis is inaugurated by the pains of
labor, which, by cutting off the capillary circulation and thus
interfering with nutrition, lead to fatty degeneration of the
muscular fibers. The products of this degeneration are absorbed
and the size of the uterus is rapidly diminished. In from twenty-
one to twenty-eight days nuclei and caudate cells make their
appearance, which develop into new muscular fibers. The
uterus at the end of eight weeks becomes normal, or nearly so.
The conditions interfering with this retrogressive process may
be enumerated as follows:—
Cervical lacerations;
Getting up too soon after delivery;
Pelvic inflammation;
Retained products of conception ;
Non-lactation.
The importance of cervical lacerations and injuries cannot be
overestimated. If such lacerations, healed kindly, the outcome
would be different, but they unfortunately often do not. As a
result cicatricial tissue is formed, which not only interferes
with the circulation of the uterus, but by squeezing terminal
nerve fibers gives rise to reflex symptoms with resulting nervous
depression and vice of nutrition. In this way involution is not
only arrested, but hypergenesis of tissue, owing to the unnatural
and embarrassed circulation, takes place.
There is yet another way by which cervical lacerations inter-
fere with the return of the uterus to its normal state. Lateral
448
A TEXT-BOOK OF GYNECOLOGY.
tears of any great extent approach so closely the folds of the
broad ligaments (even extending into them) as to set up in-
flammation of the invested cellular tissue. An inflammation
thus excited adds greatly to the uterine congestion, as does
any form of periuterine inflammation. It is exceedingly diffi-
cult to cure a cellulitis of this origin without first repairing the
cervix.
Non-lactation is a frequent cause of subinvolution. There
exists an almost mysterious connection between the mammæ and
the uterus. The application of the child to the breast gives rise
to uterine contractions which promote involution. Without this
stimulus the uterus is apt to remain large. This is one reason
why subinvolution more often follows abortion and premature
labor. Another, and to my mind quite as potent a cause, is
getting up too soon after early abortions.
The remaining enumerated causes giving rise to undue con-
gestion of the uterus and the pelvic organs are self-explanatory.
Varieties.-Hyperplasia uteri may be limited either to the
body or the cervix; or it may involve the entire uterus. In
hyperplasia of the cervix laceration usually complicates the
disease. This must not be confounded with hypertrophic elon-
gation of the cervix, a lesion which is elsewhere dealt with.
There probably is more or less hyperplasia in hypertrophic
elongation, but the deformity produced in the disease now being
considered is very different from that of the latter affection.
Again, there may be a cirumscribed area of hyperplastic tissue
in the uterine wall which simulates a small fibroid.
When the hyperplasia is limited to the cervix the distortion
is sometimes of the most marked character. I once saw a
cervix thus distorted, which was almost as large as the doubled
fist, and which nearly filled the entire pelvis. The patient was re-
ferred to me by Dr. Geo. W. Bailey of Buchanan, Mich. The
uterus was immovably fixed by periuterine inflammation; there
was a bad cervical laceration, and, as she was about fifty years of
age, I much feared malignancy. Subsequent treatment so reduced
the disease as to justify trachelorrhaphy, and an ultimate cure
resulted. Malignancy is often suggested by the conditions pres-
ent, and much care is necessary in making a diagnosis.
CHRONIC METRITIS.
449
The cervix is much more frequently affected than is the body,
though involvement of the latter is by no means rare.
A
Symptoms. These depend somewhat upon the degree of
hyperplasia and the part of the uterus affected, but much more
upon the complicating lesions.
During the early stages of subinvolution, while the tissues are
yet soft and vascular, hypersecretion is a prominent symptom.
This manifests itself in the form of a profuse leucorrheal dis-
charge and the recurrence of menstruation, or at least a uterine
hemorrhage, even though the patient nurse her child. If there be
granular degeneration of the cervix a slight hemorrhage often
follows coition, or is excited by straining at stool. Owing to
the increased weight of the organ displacements are common,
and the functions of the bladder and the rectum are more or
less interfered with.
As the disease becomes more chronic, and the stage of
hyperplasia is reached, the symptoms are less acute, but, never-
theless, marked. The leucorrhea and hemorrhage will be
governed by the amount of endometritis existing with the
hyperplasia—in fungoid endometritis the hemorrhage may be
the one symptom for which the patient consults the physician.
As the disease progresses, however, menstruation may become
less and less in quantity until finally it ceases entirely.
Other symptoms common to both stages are :—
Weight and bearing-down sensation within the pelvis, aggra-
vated by walking, standing, etc.;
Dysmenorrhea;
Gastro-intestinal disorders, as nausea, vomiting, capricious
appetite, flatulency, constipation, etc.;
Pain in the back and loins;
Pain and swelling of mammæ, especially just before and
during menstruation;
Headache;
Dyspareunia;
Reflex pains in any and every part of the body;
Mental depression and hysterical manifestations;
Vesical and rectal tenesmus;
Sterility.
29
450
A TEXT-BOOK OF GYNECOLOGY.
Dyspareunia is much wore common in hyperplasia of the
cervix than when the disease is confined to the fundus, though
pain on sexual intercourse is sometimes very intense in cor-
poreal hyperplasia.
It will be observed that there are no subjective symptoms
attending the disease that are in any way pathognomonic. The
same phenomena may result from chronic cervical or corporeal
endometritis, and, indeed, from many other lesions of the pelvis ;
or one or all may be absent in a given case. As already sug-
gested, the symptoms really depend more upon the compli-
cations-lacerations, displacements, endometritis, etc.-than
upon the changes in the parenchyma of the uterus. This being
so, we are compelled to rely largely upon physical signs for
diagnostic purposes.
Physical Signs.-In cervical hyperplasia digital examination
will reveal the cervix tender and enlarged. The external os is or-
dinarily much dilated, especially if there be laceration with ever-
sion. The cervix has usually descended so as to rest upon the
pelvic floor, and it can be distinctly felt through the rectum,
upon which it almost always impinges. It is characterized by
a peculiar hardness after the stage of hyperplasia is reached,
which strongly suggests malignant infiltration.
In corporeal hyperplasia the uterus will be found, upon
bimanual examination, enlarged, and unnaturally tender. The
sound will show increased depth of the uterine cavity. If the
abdominal walls are not too fleshy, it may be possible to deter-
mine through them increased thickness of the uterine walls
though, in perhaps the majority of cases of uncomplicated
hyperplasia, the uterine cavity remains normal as regards length.
During the early stages of subinvolution the tissues, instead
of being harder than normal, are soft, and the uterus is increased
in size in all of its diameters.
Differentiation.-There is some danger of confounding the
disease under consideration with:-
Early pregnancy;
Uterine fibroids;
Scirrhus of the cervix.
Early Pregnancy.—The pregnant uterus is more globular than
CHRONIC METRITIS.
451
when the enlargement is due to hyperplasia; it is much softer,
and it is often possible to detect, upon conjoined manipulation, a
peculiar tenesmus, and sometimes a rhythmical action; it is not
tender, and there is usually amenorrhea as well as other signs
of pregnancy.
The confusion may, nevertheless, be very great, especially if
endometritis exist with corporeal hyperplasia, for, with the en-
largement of the uterus, there may be also enlargement of the
breasts, darkening of the areolæ, nausea, and vomiting, etc.
Menstruation rarely ceases in hyperplasia, but it must not be
forgotten that occasionally menstruation continues during early
pregnancy.
Uterine Fibroids.-It is many times utterly impossible to
differentiate small fibroids imbedded in the uterine wall from
hyperplasia with enlargement. Menorrhagia is usually more
marked in the former condition, there is less sensitiveness, and
the enlargement is more localized and less uniform. Positive
differentiation can only be made by dilating the cervix and
exploring with the finger.
Scirrhus of the Cervix.-The following comparison will aid
the reader in differentiating between areolar hyperplasia of the
cervix and scirrhous degeneration:—
Areolar Hyperplasia.
The cervix feels like dense fibrous tissue.
These tissues are softened by proper
treatment.
The body is often implicated.
Tendency to hemorrhage not marked.
The mucous membrane moves over sub-
jacent tissue.
Absence of cachexia.
No tendency to break down.
Scirrhous Cancer.
It feels more like cartilage.
They are not so affected.
The body is rarely implicated during the
early stages.
Tendency to hemorrhage marked.
The mucous membrane is attached to
subjacent tissue.
Presence of cachexia.
Tendency to break down.
It is yet a mooted question as to whether hyperplasia of the
cervix ever takes on malignant degeneration. When cervical
lacerations complicate the disease most authorities are agreed
that, though not of frequent occurrence, such degeneration
may occur.
Prognosis.-There are few cases of hyperplasia of the body
452
A TEXT-BOOK OF GYNECOLOGY.
of the uterus that can be absolutely cured, so far as restoring
the parts to their normal condition is concerned. Much relief
can, however, in most instances be afforded, and if the patient is
approaching the change of life a complete cure may follow the
cessation of menstruation. On the other hand, uterine hemor-
rhage may continue indefinitely after ovulation ceases, especially
if the endometrium is involved. Under the most favorable cir-
cumstances much time is required to benefit a case of long-
standing corporeal hyperplasia.
When the disease is limited to the cervix the prognosis is not
so sinister, for the parts can be gotten at and treatment more
advantageously applied. When the changes are due to cervical
lacerations the most decided improvement usually follows repar-
ation of the tears.
TREATMENT.
General Treatment.-There are certain general measures
applicable to all of the various affections included in this chapter.
These should be directed, first of all, toward any diathetic
taint that may be present, and to the improvement of nutrition
by a properly selected diet. Exercise in the open air, short of
fatigue, should be prescribed. Sea-bathing, or, if this is not
possible, the daily use of the sitz-bath, will accomplish much
good in most cases. Massage and the rest cure are sometimes
indicated, though, as a general rule, moderate outdoor exercise
is to be encouraged. The bowels should be kept regular and
the urinary functions looked after.
Sexual intercourse, if indulged in at all, should occur at long
intervals and in the most natural way. On the whole, it is better
for the patient to live absque marito during treatment. In my
experience it is exceedingly difficult to cure or benefit any
of the diseases under consideration so long as the patient keeps
her pelvic organs constantly congested by any one of the various
expedients whose object is to prevent conception.
Any or all conditions or causes tending to keep up pelvic con-
gestion should receive attention. The clothing ought to be
suspended from the shoulders instead of constricting the waist
and crowding the abdominal organs into the pelvis.

TREATMENT OF CHRONIC ENDOMETRITIS AND METRITIS. 453
Measures having for their object the promotion of uterine
contraction and the complete emptying of the organ following
delivery at term or abortions should be applied. I have, in dealing
with acute pelvic inflammation, especially emphasized this point.
Local Treatment.-In chronic cervical endometritis the indica-
tions to be covered are:-
1. Any cause tending to perpetuate the catarrhal process
should be removed.
2. The parts should be kept thoroughly clean.
3. Congestion should be overcome by the intelligent use of
the hot douche.
4. Medicaments should be applied to the diseased surface.
FIG. 75-
FIG. 76.
CONOID CERVIX, PINHOLE OS.
(Palmer.)
DILATED CANAL FROM OBSTRUC-
TION OF OS EXTERNUM; LINES
FOR INCISION. (Munde.)
Of the removable local causes, we have to do with displace-
ments, lacerations, distorted cervices, periuterine inflammation,
etc. In dealing with cervical lacerations we are hardly justified
in operating until the local disease has been overcome or greatly
improved; the cervix is then repaired for the purpose of pro-
moting its return to a normal state. Pessaries must be used with
much circumspection while the endocervicitis is at all severe.
It is better in these cases to correct the displacement as nearly
as possible by means of the vaginal tampon.
454
A TEXT-BOOK OF GYNECOLOGY.
The form of distorted cervix calling for operative interference
is well shown in Figs. 75 and 76. It is in such conditions as are
there shown that quite extensive disease may continue indefinitely
without causing the external os to gape. As a consequence, the
discharges are retained, the cervical canal becomes dilated, and
treatment is interfered with. To overcome this condition the
hard steel dilators (Fig. 44) should be introduced and the os en-
larged. I prefer this method to that of gradual dilatation by the
hard rubber dilators (Fig. 43). Thomas and Mundé prefer
to incise the cervix, as is shown by the vertical lines in Fig. 76.
In my experience simple dilatation has been all that is neces-
sary.
The vaginal douche is useful both for the purpose of cleansing
the parts and overcoming congestion by contracting the blood-
vessels. I instruct my patient, in dealing with the condition
under consideration, to use the douche at least once a day, pre-
ferably twice, and always a short time before presenting herself
for treatment.
In dealing with granular and cystic degeneration it is often
necessary to remove the diseased tissue, either with a pair of
scissors or with the sharp curette, before much good will come
from the use of local medicaments. In cystic degeneration all
that may be necessary is to empty all of the cysts by punctur-
ing them with the point of a tenotomy knife, forcing out their
contents, and applying to their bases nitrate of silver, nitric
or chromic acid. Although I have never used the galvano-
cautery for this purpose, yet it strikes me as a good way of
destroying the cysts. In very extensive degeneration it may be
necessary to amputate a portion of the cervix.
As regards local medication, I have likewise expressed my views
in full in Chapter X. I believe that it will rarely be necessary
to resort to the more powerful application of nitric acid, chromic
acid, etc., if each case is treated, not in a routine way, but ac-
cording to the indications which present themselves. There is,
however, one agent not treated of in the chapter referred to, which,
in my hands and in the experience of some of my colleagues, has
proved most serviceable. I refer to galvanism. Since using it
I am confident that I am curing my patients in a much shorter
TREATMENT OF CHRONIC ENDOMETRITIS AND METRITIS. 455
time than formerly. I append to this chapter several illustrative
cases showing its usefulness and the method of its application
in general endometritis and metritis. I will simply state at this
time that when the disease is limited to the cervix, negative
cauterization, with from ten to seventy-five milliampères, will
ordinarily change the condition for the better very quickly.
The applications should be made from two to three times a week
for at least three or four weeks.
By no means do all cases of cervical endometritis require
local treatment other than the patient can administer herself by
the use of the hot douche and some liquid medicament. I
rarely subject a young unmarried woman to a local examination
for leucorrhea alone until an effort has been made to cure the
discharge by general measures and the more simple local ones
just referred to.
Chronic Corporeal Endometritis.-This affection is so frequently
associated with, and, indeed, so often is the cause of, menorrhagia
and other menstrual troubles that I have, in the chapter devoted
to uterine hemorrhage, described my method of dealing with it.
The persistent use of the vaginal douche, the intra-uterine
applications of the compound tincture of iodin and carbolic
acid, followed by the boro-glycerid tampon, is the classical
method of local treatment, and, it must be confessed, much good
often results from this treatment continued for several weeks or
months. Galvanism, too, is a most valuable agent, and I rarely
resort to the more radical treatment of divulsion and curetting
until galvanism has been given a fair trial. Notwithstanding
the intelligent and faithful use of these methods, we will every
now and then meet with cases little improved by them. This
is particularly true when fungoid endometritis exists, and it is
in such cases that curetting does so much good. After the cur-
etting and the application of the proper medicament (I have
found the compound tincture of iodin or the impure carbolic
acid sufficiently powerful; Dr. Mundé prefers a 50 per cent.
solution of chlorid of zinc), a strip of iodoform gauze, with one
end projecting, should be passed into the uterine cavity to keep
the walls separated. A tampon is placed against this and the
patient put to bed, where she is to remain for a week. Subse-
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A TEXT-BOOK OF GYNECOLOGY.
quent office applications for five or six weeks are usually
necessary.
*
The foregoing measures are heroic, but since we are dealing
with a most obstinate affection, heroic measures are imperative.
By observing the counter-indications and proper antiseptic pre-
cautions there is really but little danger attending the use of the
curette, while the good accomplished more than compensates for
the enforced confinement.
I do not attribute all of the benefit derived from this oper-
ation to the curetting alone, for the measures applied promote
drainage of the uterine cavity, the importance of which is
especially emphasized by Dr. Gil. C. Wylie of New York. I
am convinced that the principle of drainage, as applied to the
uterine cavity, is a broad one, and applicable to all forms of
endometritis.
Subinvolution and Areolar Hyperplasia.-The local measures
applicable to these conditions do not differ essentially from those
recommended for the two forms of endometritis. When we
have the management of lying-in cases, we should promote
involution, by thoroughly emptying the uterus, and insist
upon the patient's remaining in bed until the fundus can no
longer be felt above the pubes; we should encourage, unless
positive counter-indications prevail, lactation; and, finally, we
should advise against the resuming of marital relations until
involution of all of the genital organs is complete.
Other local measures should be directed toward the removal of
those complications upon which the uterine changes in no small
degree depend. Such are cervical lacerations, endometritis, granu-
lar and cystic degeneration of the cervix, fungoid degeneration of
the endometrium, injuries to the pelvic floor, uterine displace-
ments, etc. It may be necessary, if the changes in the cervix
are very great, to remove a portion of it as is recommended in
hypertrophic elongation of this organ.
The hot douche, if it does good at all, must be used even more
persistently than in cervical and corporeal endometritis.
should be continued for fifteen or twenty minutes at a time.
It
* A 10 per cent. solution of chlorid of zinc and carbolic acid, in glycerin, is a
useful application for office work in these cases.
TREATMENT OF CHRONIC ENDOMETRITIS AND METRITIS. 457
Local alteratives are to be used as in endometritis, and un-
doubtedly do much good.
The most useful of all agents is, however, electricity. I do not
resort to electro-puncture, as recommended by Apostoli, but use
one or the other pole direct within the uterus. If the parts are
very vascular and the tissues soft, or if pain is marked, the positive
is used direct; if, on the contrary, the tissues are hard and
indurated, the negative electrode should be passed into the
uterine cavity. If the positive pole be used direct it should be
constructed of platinum. I have rarely seen any good come
from a current of less than twenty-five milliampères, unless the
chief object is to relieve pain, when one of this strength will
ordinarily suffice. However, if the patient can tolerate a current
of seventy-five or one hundred milliampères so much the better.
At least two applications a week should be made. It must, too,
be persisted in for weeks or even for months.
Illustrative Cases.
CASE LX. Corporeal and Cervical Endometritis.—Miss æt. 22, had been
under my care off and on for three years, suffering from corporeal and cervical
endometritis. She suffered from reflex symptoms too numerous to mention, the one
giving her the most distress being a severe pain in the right hip. Menstruation was
excessive, and during the menstrual period there was a profuse, purulent leucorrhea,
which was very excoriating, and gave rise to an intense pruritus. The lips of the os
were eroded, and the uterine cavity measured three inches.
The patient would greatly improve under the ordinary methods of treatment, but
soon after discontinuing them she would relapse into her former state. I finally
resorted to direct, positive galvanization, beginning with twenty-five milliampères and
ending with seventy-five. The seances varied in time from one to five minutes, and
were repeated twice a week for four weeks. The internal electrode was Martin's
flexible platinum instrument, and I was careful to have the metal come in contact with
the entire endometrium, including that of the cervix.
Improvement followed the first application, and after the eighth I discharged her.
The uterus was still somewhat larger than normal, but the discharge had ceased,
the erosion was overcome, and the cervix had a normal appearance. The patient im-
⚫proved in every respect, and is now, six months later, quite well.
CASE LXI. Areolar Hyperplasia.—Mrs. æt 52. The uterus in this case was
hard, dense, and tender, and measured three inches. Menstruation had ceased two
years before consulting me. The patient complained of constant pressure and pain in
the uterine region. Because of the pain I first used positive galvanization, but after
three or four applications the negative pole was used direct. The applications were
made twice a week. At the end of eight weeks she reported herself entirely free, not
458
A TEXT-BOOK OF GYNECOLOGY.
only from the local pain and distress, but from the nervous and mental symptoms as
well, which at the beginning were marked.
CASE LXII. Cervical Endometritis.-Miss æt. 19, consulted me for a most
distressing dysmenorrhea. I found obstruction at the internal os with a bad chronic
cervical catarrh. The catarrh was treated in the usual way and greatly benefited, but
the dysmenorrhea persisted. Accordingly, I resorted to forcible divulsion under ether,
inserted a cervical plug, and kept the patient in bed for a week. This operation com-
pletely relieved the dysmenorrhea, but the cervical catarrh returned worse than before.
I then resorted to local negative cauterization with the most happy results. The
catarrh was entirely cured by four applications.
The foregoing cases are but a few of the many passing under
my observation. The applications, in all instances, were followed
by the boro-glycerid tampon and sometimes by direct medication
with iodin or carbolic acid. The hot douche and the indicated
remedy were also faithfully used in all instances. In addition to
these, I will quote in full three cases from Massey's “ Electricity
in the Diseases of Women.” *
CASE LXIII. Chronic Purulent Endometritis of Five Years' Duration. Com-
plete Relief after Eight Negative Cauterizations.-E. L., married, aged 37 years, was
seen first in private practice early in March, 1888. She had suffered from hemorrhage
five years before, which had left her with a constant, abundant leucorrhea of a green-
ish-white color and offensive odor. Menstruation was regular, abundant, and attended
with considerable pain. Examination showed an eroded os with thickened lips.
Uterus two and a half inches, plus, anteflexed, and slightly hypertrophied. At this
visit, thirty milliampères, negative, were applied to the endometrium for five minutes.
The odor from the discharge was so offensive as to necessitate opening the office
windows.
March 12th. Discharge clearer and less abundant. Negative cauterization, eighty
milliampères, four minutes.
March 16th. Electrode introduced with greater ease. Negative cauterization, one
hundred milliampères, four minutes.
March 18th. Negative cauterization, one hundred milliampères, four minutes.
Discharge clearer and much less offensive.
March 20th. Negative cauterization, eighty milliampères, three minutes. Her
menstrual period followed several days later, normal in amount and duration, and at-
tended with less pain than at any time for years. Several similiar applications were
made during the next intermenstrual period, when it was noticed that the discharge
was much lessened in amount, and entirely free from odor. The second inter-
menstrual period was free from discharge of any kind. Eight months later the
patient was seen, and stated that she had remained entirely well since.
CASE LXIV. Chronic Metritis of Five Years' Duration. Uterus Reduced to
Normal Size and Disappearance of Symptoms after Five Applications to Cavity.—
Mrs. M. S., aged 38, mother of one child 10 years old. Five years ago had a mis-
* Op. cit., second edition.
TREATMENT OF CHRONIC ENDOMETRITIS AND METRITIS. 459
carriage, and has been ill ever since. Suffers from pain in the right groin, which is
sore and tender to touch. Menstruation every three weeks; flow normal, with
severe bearing-down pains. Has a continuous intermenstrual backache and leucor-
rhea.
Examination November 25, 1889, showed an enlarged and prolapsed uterus,
adherent to the right. Manipulation caused considerable pain. Os eroded and
exuded muco-purulent matter; cavity three and a half inches. Forty-five milliam-
pères, positive, were applied to the cavity for two minutes.
December 9th. Soreness and backache better. Positive cauterization of cavity.
Forty-five milliampères, one minute.
December 27th. Menstrual flow since last treatment, unaccompanied by pain for
the first time in five years. Cavity three inches. Positive cauterization, forty-five
milliampères, two minutes.
December 30th. More pain than usual. Positive cauterization, forty-five milliam-
pères, two minutes.
January 3, 1890. Uterus in normal position and freely movable, with but slight
pain. Shortening and slight thickening in region of broad ligament. Cavity two
and a half inches, but some leucorrhea continues.
January 17th. Menstruation at third week. Again painless. Leucorrhea slight.
Positive cauterization, twenty-five milliampères, two minutes.
January 27th. Leucorrhea more watery. Positive cauterization, forty milliam-
pères, three minutes.
February 10th. Menstrual flow normal and painless. Cavity two and a half
inches. No leucorrhea since last period.
CASE LXV. Chronic Metritis of Two Years' Duration. Complete Relief
After Three Applications.—Mrs. M. H., aged 31, was seen at Howard Hospital in
July, 1889. She had had eight children and one miscarriage, the latter two years
before, since which she had been ailing. Pain in back, left side, and head, with abun-
dant leucorrhea. Walking difficult. Examination: Uterus hypertrophied, os slightly
lacerated, cavity three inches, purulent discharge from uterus. Tenderness in both
ovarian regions. She was given three negative cauterizations of fifty milliam-
pères each at intervals of one week. After the next period she reported com-
plete relief of all symptoms, and the cavity was found to be but two and one-half
inches.
Therapeutics.
Hydrastis Canad.-TENACIOUS DISCHARGE; erosion and su-
perficial ulceration of the cervix and vagina; great sinking and
prostration at the epigastrium, with violent and continued palpita-
tion of the heart; leucorrhea, complicated with hepatic derange-
ment and constipation.*
* "The general condition of the patient will often afford the strongest indication
for the use of hydrastis, namely, the cachectic state, the weak muscular powers, the
poor digestion, and the obstinate constipation."—Hale.
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A TEXT-BOOK OF GYNECOLOGY.
Calcaria carb.—LEUCOPHLEGMATIC CONSTITUTION; menses too
profuse and too often; the feet feel cold and damp; albuminous
leucorrhea from the cervical canal with great lassitude and de-
bility. "Every current of cool air seems to go through and
through the patient.”—Guernsey.
Conium mac.-Leucorrhea of a white, acrid mucus, causing
a burning or smarting sensation; prolapsus uteri complicated with
INDURATION, ulceration, and profuse leucorrhea. "One of the
best remedies in induration, especially of a scrofulous nature.”
—Lilienthal.
Mercurius.-Lancinating, boring, or pressing pain; discharge
variable in character, all symptoms worse at night; much perspira-
tion, which affords no relief; MOIST TONGUE, often accompanied
with intense thirst; gonorrheal or syphilitic complications.
Kreasotum.-Leucorrhea of a yellow color, staining linen
yellow, with great weakness; exceedingly corroding leucorrhea,
causing redness and itching in the vulva; menses too early, too
profuse, and too long.*
Sepia.-Pain in uterus, which extends from back to abdomen
with bearing down; crosses limbs to prevent protrusion of parts;
redness, swelling, and itching eruption of labia; great sense of
emptiness in pit of stomach.
Murex. A feeling as though something were pressing on a
sore spot in the pelvis (Betts); thick, green, or bloody leucor-
rhea; sexual erethism.
Graphites.—Particularly when the ovaries are affected;
scanty menses; IRRITABLE SKIN; weakness in the back and
small of back when sitting or walking.
Borax.-White albuminous leucorrhea; leucorrhea midway
between the menstrual periods. Like all of the other secre-
tions of borax, the leucorrhea has an unnatural warmth or heat
to it."-Farrington.
* "The acridity of the leucorrhea marks clearly the divergence of kreosote from
sepia, as well as from murex. This led to the employment of the drug in cancerous
and other forms of ulceration of the cervix uteri, and we now choose it when there
are burning, sensitiveness, and tumefaction of the cervix, with bloody, ichorous dis-
charges; sensitiveness to touch or to coitus; and a putridity, which is foreign to the
other two remedies."-Farrington.
་
TREATMENT OF CHRONIC ENDOMETRITIS AND METRITIS. 461
A
Pulsatilla.-Thin, acrid leucorrhea, or thick, white mucus,
most profuse after menses; tensive, cutting pain in uterus,
which is very sensitive to touch or to coitus; amenorrhea.*
Arsenicum.-Leucorrhea in women of pale, waxy complexion;
prostration; acrid, free discharge; vomiting immediately after
taking food; amenorrhea.
Aurum.-Syphilitic and scrofulous endometritis; induration
and prolapsus of the uterus; great nervous weakness with utter
despair.
Lachesis. She cannot bear any pressure, not even of the
clothes, over the uterine region; metritis during the critical age
with FLUSHES OF HEAT; sensation as if the pains were ascending
toward the chest; aggravation after sleep.
Sabina.-Pain from sacrum or lumbar region to pubes;
metrorrhagia of clotted and fluid blood.†
Secale.-Subinvolution with putrescence of leucorrheal dis-
charge; great debility, with tingling in lower extremities. ‡
Caulophyllum.-Insomnia, paraplegia, atony, and relaxed
condition of the uterus; hysterical spasms; menses excessive
and irregular.
Helonias.-Leucorrhea giving rise to intense pruritus, with
heat and swelling of the vulva; GREAT DEBILITY; melancholia,
with a sensation of weight; soreness and dragging in the
uterus.
Cimicifuga.-SEVERE PAINS IN THE SMALL OF THE BACK,
down the thighs, and through the hips, with heavy pressing
down; the patient is nervous, neuralgic, and hyperesthetic, but not
so hysterical as the ignatia patient (D. Dyce Brown); sensitive-
ness of all of the pelvic organs, especially the ovaries; INSOM-
NIA; MELANCHOLIA.
*"In simple mucous leucorrhea pulsatilla is often curative; and in dysmenor-
rhea, when the little blood which flows is black and coagulated, and when diarrhea is
wont to occur at the periods."-Hughes.
+"Consentaneous rectal and vesical irritation adds weight to the indications for
the choice of sabina in utero-ovarian disorders."-Hughes.
“The secale cor. may, perhaps, be the only remedy required in the treatment of
subinvolution. I have treated several such cases successfully with it alone. My
preference is for the second or third dilution."—Ludlam.
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A TEXT-BOOK OF GYNECOLOGY.
Nux vom.-Violent aching in the hypogastrium, aggravated
by pressure and contact; cONSTIPATION; aggravation toward
morning.
Sulphur.-Vulva excoriates easily; frequent flushes of heat;
weak and fainting spells, with strong craving for food.
Iodium.-Acute pain in the mammæ, developed by the
metritis; emaciation and low cachectic state of the system, with
feeble pulse; ATROPHY OF THE MAMMÆ.
Kali bich.-Leucorrhea that can be drawn out in long strings,
yellow, ropy, stiffening the linen.
Consult :-Kali carb., MAGNESIUM MUR., stramonium, kali sulph,
rhus tox., nitric acid, phosphorus, and silicea.
CHAPTER XXX.
INTRA- AND EXTRA-PERITONEAL PELVIC
HEMATOCELE.
Definition.-An effusion of blood, which becomes organized,
either within the pelvic peritoneal cavity or in the subjacent
cellular tissue, is called a pelvic hematocele. When the blood
is poured into the free peritoneal cavity, it constitutes an intra-
peritoneal hematocele; when it finds its way beneath the peri-
toneum, usually between the folds of the broad ligaments, it is
known as extra-peritoneal. In order to constitute a true hema-
tocele in either event it must become encysted. Blood poured
into the free peritoneal cavity, which is not shut off by a limit-
ing membrane, is better defined by the term intra-peritoneal
hemorrhage. The encysted effusions constitute a distinct, morbid
condition very different from non-encysted effusions.
Certain terms are used to indicate the location of the effu-
sion. Thus, if back of the uterus, it is called a retro-uterine
hematocele; if in the cellular tissue surrounding this organ, peri-
uterine; if in the cellular tissue surrounding the rectum or the
vagina, peri-rectal, peri-vaginal, etc.
INTRA-PERITONEAL HEMATOCELE.
Etiology. The causes of this accident are both predisposing
and exciting. The predisposing causes are:-
Age of sexual vigor;
The various blood affections, as plethora, anemia, and
hemophilia;
Uterine diseases.
The exciting causes are :—
Traumatism ;
Intra-vaginal and intra-uterine injections;
Excessive or intemperate coition ;
Obstruction of the Fallopian tubes.
463
464
A TEXT-BOOK OF GYNECOLOGY.
A pelvic hematocele rarely occurs before the age of fifteen or
after the age of fifty. During the interval between these ages all
of the functions pertaining to the sexual organs are active. The
sexual relations undoubtedly predispose, both directly and indi-
rectly, to the formation of hematocele. Directly, because of the
increased congestion of the pelvic organs resulting from the
sexual act, and especially from the various means resorted to for
the purpose of preventing conception; indirectly, because of the
not infrequent occurrence of extra-uterine pregnancy. It is
maintained by Lawson Tait that a ruptured extra-uterine preg-
nancy cyst is, in nearly all instances, the cause of pelvic hemato-
cele. While it is probably a very frequent cause neither the
weight of authority nor clinical evidence, justifies so sweeping an
assertion.
In the several conditions characterized by intravascular pressure
there is, of course, a greater tendency to rupture of the vessels
in all parts of the body. Such a condition prevails in plethora,
and plethoric women, particularly if the hemorrhagic diathesis is
a feature of the changed blood state, are liable to have hematocele.
Conversely, anemia, chlorosis, and, indeed, all forms of depravity
of the blood, predispose to hematocele, notwithstanding the
diminished intra-arterial pressure. The explanation here is, that
the resistance of the walls of the blood-vessels is weakened; if
from any cause a temporary congestion is induced a rupture
may occur.
The various uterine affections predispose to hematocele be-
cause of the increased pelvic congestion to which they usually
give rise, and because also of the cervical obstruction which
so often results from such affections. The blood, not being able
to escape readily from the cervical canal, is retained, the uterus
becomes distended, and a reflux through the Fallopian tubes into
the pelvic cavity takes place.
Traumatism is not an infrequent cause. The accident may result
from lifting, straining, kicks, blows, falls, etc. It follows not infre-
quently after operations upon the uterus or within the pelvis,
though, as a result of oöphorectomy, hemorrhage is oftener
effused beneath the peritoneum.
Obstruction of the Fallopian tubes, by preventing the entrance
INTRA-PERITONEAL HEMATOCELE.
465
of blood into the uterus during menstruation, may divert the
hemorrhage through the fimbriated extremities into the perito-
neal cavity; hematoceles from this cause are usually small.
Sources of the Blood.-The hemorrhage may have its
origin from several different sources. Undoubtedly, one of the
most frequent is a ruptured extra-uterine pregnancy cyst. This
will be referred to again in dealing with that particular ac-
cident.
It may be derived from the tubes; it is probable that the
mucous membrane of the tubes pours out more or less blood in
normal menstruation. If, from any cause, it cannot reach the
uterine cavity, it takes the direction of least resistance and
escapes from the fimbriated extremities of the canals. That this
is true is shown by the fact that in many cases of hematocele the
tubes are distended with blood. The amount of hemorrhage
in these cases is usually not great, and, if the peritoneum is in a
perfectly normal condition and the blood not abnormally irrita-
ting, the fluid is quickly absorbed and no tumor is formed. The
same may be said of hemorrhage from a ruptured Graafian
follicle. No great amount of blood ordinarily escapes from this
source. Under the head of sterility I have alluded to the
improbability of even the majority of extruded ovules finding
their way into the Fallopian tubes. The ovule and the slight
hemorrhage attending dehiscence of the Graafian follicles escape
into the peritoneal cavity. The resulting distress is usually not
great, but the frequent attacks of localized peritonitis during
menstruation are often due to this cause.
Richet particularly emphasizes the importance of varicosis
of the utero-ovarian venous plexus as a causative factor in the
production of hematocele. This plexus is often unnaturally en-
larged, which condition constitutes "varicocele of the female."
Virchow affirms that the veins which make up this plexus, when
they become varicosed, frequently contain phlebolites, which give
rise to ulceration of their walls. Whatever may be the cause of
the weakened condition of these veins their rupture gives rise to
profuse hemorrhage, for the plexus is a large one.
The older authorities taught that a hemorrhage proceeds, not
infrequently, from a preëxisting pachyperitonitis. Most modern
30

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A TEXT-BOOK OF GYNECOLOGY.
writers contend that the importance of this condition in the
production of hematocele has been exaggerated.
Pathology. In nearly all instances when blood finds its way
into the free pelvic peritoneal cavity, it gravitates, unless prevented
from so doing by previously formed adhesions, into the Douglas
cul-de-sac. This is because the cul-de-sac is the most dependent
part of the peritoneal cavity. In the event of its obliteration
by previous disease, the next most dependent part is the utero-
vesical pouch. If the quantity of blood is not great, it is limited
FIG. 77-
INTRAPERITONEAL HEMATOCELE,
The coagulated blood completely surrounds the uterus and covers the superior surface
of the bladder and the anterior surface of the rectum. The small intestines are
pushed upward.
to one or the other of these pouches. When, however, more
blood escapes than can be contained in either of these localities,
it may fill the entire pelvis, and, indeed, extend as high as the
umbilicus. A very large hematocele is shown in Fig. 77.
Here the uterus and all of the pelvic organs are embedded in,
and surrounded by, the encysted fluid.
INTRA-PERITONEAL HEMATOCELE.
467
The contact of the blood with the peritoneum causes the
latter to inflame, and a protective lymph is quickly thrown
out, which separates the fluid from the intestines and organs
above. This neo-membrane at times so closely resembles in
appearance the normal peritoneum as to make it difficult to
distinguish the one from the other even after the abdomen is
opened. It is probable that, because of this fact, intra-peritoneal
hematocele has more than once been mistaken for the extra-
peritoneal variety.
If the amount of blood is not great, and does not surround
the uterus, the sac is bounded in front by the posterior wall of
that organ; latterly, by the utero-sacral ligaments and walls of
the pelvis; and posteriorly, by the rectum and posterior pelvic
wall. Frequently the ovaries and tubes adhere to the walls of
the sac and are blended with it. Adhesions of the intestines
are of common occurrence.
The quantity of the effusion is sometimes limited by a pre-
existing false membrane.
The blood, when it first escapes, is liquid. Its watery por-
tions are, however, quickly absorbed, when it becomes semi-
liquid and coagulated, and, as time progresses, solid. These
are the usual changes. Sometimes it remains semi-liquid or
sirupy, and shows no tendency to coagulate. There is usually
some septic taint when this is the case.
The walls of the sac vary in thickness, at some portions being
quite thick, at others so thin as easily to rupture.
Fig. 77 shows how great is the distortion of the rectum and
the bladder by the pressure of the tumor. The rectum is some-
times so impinged upon as to be completely occluded, and the
function of defecation is almost always disturbed to a greater or
less extent. So, too, is the function of micturition; indeed, in
some of the worst cases the pressure upon the urethra may entirely
occlude this canal.
When the affection has for its cause a ruptured extra-uterine
pregnancy cyst, it may be impossible to find any evidences of the
fetus after the abdomen is opened, rupture having occurred before
it is sufficiently developed to make its detection an easy matter.
A careful search will, in most instances, reveal some of the re-
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A TEXT-BOOK OF GYNECOLOGY.
mains of the chorion. It is this difficulty in detecting the evidences
of early extra-uterine pregnancies which has led Tait to make the
somewhat sweeping assertion already referred to.
Symptoms. The onset may be either sudden or gradual. A
careful inquiry will often reveal the history of certain premoni-
tory symptoms pertaining to the function of menstruation or to
the pelvic organs. Menstruation has, perhaps, been more or less
disturbed for some time previously to the onset. Some of the
signs of salpingitis may have presented; and, in the event of
extra-uterine pregnancy, irregular spasmodic pains in the region
of one or the other Fallopian tube may have preceded the rup-
ture. Gastric reflexes also occur with more or less constancy in
extra-uterine pregnancy. While these premonitory symptoms
often occur, the reader must not imagine that they invariably do;
indeed, in many instances the patient has enjoyed perfect health
up to the very time of the effusion.
The intensity of the symptoms will depend in large measure
upon the quantity of blood effused. The one condition which is
more characteristic of hematocele than any other is syncope.
This is indicated by the pallor, the feeble and sometimes imper-
ceptible pulse, the subnormal temperature, the hiccough, and, in
serious cases, nausea and vomiting.
Pain may occur simultaneously with the syncope or not until
reactionary symptoms have set in. It is due to the peritonitis
excited, and to pressure upon the organs and nerves of the pelvis.
The patient will locate it in the pelvic or sacral regions, in the
bladder, or in the rectum. Sometimes pressure upon the sacral
and the crural nerves will cause intense suffering in the lower ex-
tremities. The pain does not depend so much upon the size of
the tumor as upon the degree of peritonitis excited: if the blood
is especially irritating, or if it is contaminated with pus, the
result of pre-existing pyosalpinx, a small quantity of fluid will
give rise to a great deal of suffering.
The local symptoms are very characteristic. There is almost
always tenderness over the hypogastric region, and if the blood-
tumor is large enough to reach above the pelvic brim, dulness as
well. A digital examination will reveal a tumor in some portion
of the pelvis, usually back of the uterus; or, in the event of a
INTRA-PERITONEAL HEMATOCELE.
469
large effusion impinging upon all of the fornices of the vagina,
the uterus will be found completely embedded in it. The tumor
is at first soft and fluctuating, but soon acquires a variable con-
sistence, and in time, as we have already seen in studying the
pathology, becomes hard. There is of course more or less ten-
derness within the pelvis. The bimanual examination shows
either that the uterus is in the center of the tumor; or, if the
tumor is limited to the posterior cul-de-sac, that the uterus is
pushed forward, and the cervix carried almost above the reach
of the examining finger. A rectal exploration may be impos-
sible because of the occlusion of this organ. Much valuable
information can, however, ordinarily be obtained by a rectal ex-
amination.
•
The reactionary symptoms following the syncope usually mani-
fest themselves within a few hours after the accident. The de-
gree of fever is most variable, though in most cases it is quite
marked, the temperature ranging from 102° to 105°. It is largely
due to the inflammatory symptoms attending the peritoneal ir-
ritation. The pulse corresponds to the height of the fever,
though for a time it is more compressible than it ordinarily is in
peritonitis, because of diminished intra-arterial pressure from the
loss of blood. The temperature shows exacerbations and remis-
sions, it being usually higher during the day and early part of
the night and lower in the morning. The nausea and vomiting
likewise depend largely upon the peritoneal involvement; if the
peritonitis becomes general, these symptoms are often most dis-
tressing. This is true also of tympanites. Sometimes the dis-
tention of the bowels is very great, which condition is frequently
associated with nausea and vomiting. Tenderness over the ab-
domen is likewise a symptom accompanying peritonitis.
Progress of the Disease.-In the event of large effusions the
course, under the most favorable circumstances, is usually chronic.
It is, nevertheless, surprising with what rapidity nature will ab-
sorb, when not interfered with, a large intra-peritoneal hematocele.
There is, in most instances, a progressive tendency to recovery
either by natural absorption or by spontaneous evacuation.
Exacerbations are, however, of frequent occurrence. They
result either from new effusions taking place from time to time,
or from an extension of the peritonitis. A recurrence of the
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A TEXT-BOOK OF GYNECOLOGY.
hemorrhage is more apt to take place in cases of extra-uterine
pregnancy, and the patient is never out of danger until the tumor
has so far diminished as to preclude the possibility of renewed
hemorrhage, or of suppuration. The process of absorption
varies greatly in its activity, requiring all the way from two
weeks to many months before it is complete.
The patient is often unable to walk for some time after assuming
the sitting posture. Uterine displacements are frequent sequelæ.
Evidences of the tumor often remain permanently in the form of
a hard nodule.
Signs of Suppuration.-Suppuration may not occur until
some time after the inflammatory symptoms have entirely subsided.
Its onset is indicated by a decided chill, or a succession of erratic
chills, followed by perspiration, fever, tympanites, etc. The tumor,
which had previously diminished more or less in size, increases,
and in time becomes soft at some point. Unless artificially
evacuated, the pus will find its way either into some of the cavities
of the pelvis or through the abdominal wall externally. It most
frequently escapes into the rectum, which gives rise to more or
less proctitis, the pus being blackish and exceedingly fetid.
When the abscess discharges into the vagina the point of rupture
is indicated by more or less fluctuation. Fortunately, rupture
rarely occurs into the peritoneal cavity and almost never into the
bladder. After rupture, whatever may be the point of exit,
there is a decided relief of the general symptoms and local dis-
tress, though, if the discharge continues for an indefinite length
of time, it greatly prostrates the patient and she may die from
sheer exhaustion; or, as is oftener the case, from pyemia.
Diagnosis. The early symptoms of hematocele are almost
pathognomonic. The sudden occurrence of shock, followed by
the formation of a retro-uterine tumor, which is at first fluid,
becoming gradually more or less solid as time progresses, and
the succeeding inflammatory symptoms-all point to hematocele.
The conditions liable to be confounded with it are-
Ruptured pyosalpinx and pelvic abscess;
Tumors resulting from pelvic cellulitis or peritonitis;
Tumor resulting from extra-uterine pregnancy;
Retro-uterine displacements;
Ovarian and fibroid tumors.
INTRA-PERITONEAL HEMATOCELE,
47I
Ruptured pyosalpinx and pelvic abscess give rise to but little
syncope. No tumor ensues except as a result of succeeding
peritonitis.
Pelvic cellulitis and peritonitis give rise to symptoms which
occur in a sequence different from that following hematocele.
The inflammatory symptoms precede the formation of the tumor.
There is no shock and no syncope.
The tumor resulting from extra-uterine pregnancy is of slow
formation. It is usually located laterally. There is no shock,
no syncope, and no inflammatory symptoms previously to rup-
ture.
Retro-uterine displacements may be complicated by pelvic
inflammation. A tumor in the posterior cul-de-sac due to this
cause can be penetrated by a sound passed through the cervical
canal; the bimanual will show that the fundus is not in front.
Small ovarian and fibroid tumors located in the posterior cul-
de-sac ought not to be confounded with hematocele. There is
an absence of all of the symptoms characteristic of the latter
condition, except the presence of the tumor. Careful inquiry
into the history of the case, together with a local examination,
will usually determine the true condition.
Prognosis. Intra-peritoneal hematocele is usually a most
serious condition, though, except when due to a ruptured extra-
uterine pregnancy cyst, immediate death rarely occurs. There
are certain factors which should always be carefully noted in
determining the prognosis. The hemorrhagic diathesis greatly
complicates matters, for there is a tendency in these cases to
frequent recurrences of hemorrhage.
When the system is
previously depressed by any of the constitutional diseases, the
tumor is apt to remain soft and fluctuating; this is always.
unfavorable. In the event of suppuration a spontaneous rupture
into the rectum is unfortunate, for the resulting abscess will
frequently continue to discharge indefinitely because of incom-
plete drainage. In perhaps the majority of cases plastic residues
about the uterus remain permanently, to which subsequent ill-
health can often be traced. Uterine displacements often result
from the adhesions left behind and from the changed condition
of the pelvic organs.

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A TEXT-BOOK OF GYNECOLOGY.
EXTRA-PERITONEAL HEMATOCELE.
Etiology. The same causes responsible for the intra-uterine
variety of hematocele are quite as often responsible for an effusion
of blood into the subjacent cellular tissue. As already
intimated, the accident frequently follows salpingotomies and
ovariotomies. It is probable, too, that this form of hematocele
is oftener due to extra-uterine pregnancy than is the intra-
peritoneal variety. As regards the relative frequency of the two
FIG. 78.
EXTRA-PERITONEAL HEMATOCELE,
The blood is effused into the pelvic cellular tissue, elevating the pelvic peritoneum
and pushing the uterus forward and to one side. All but the cervical portion of
the uterus is concealed. (Auvard and Devy.)
forms, there exists a difference of opinion among the authorities,
owing to the fact that intra-peritoneal hematocele is oftener fatal.
The older writers, because of this fact, believed the latter to be by
all odds the more frequent form. Information obtained by ab-
dominal surgery has thrown new light upon the subject. We
now know that when the blood is limited by the peritoneum,
death rarely if ever occurs.

EXTRA-PERITONEAL HEMATOCELE.
473
It is probable, as taught by Tait, that there are many cases of
extra-uterine pregnancy which rupture into the folds of the
broad ligaments, giving rise to hematocele; if the fetus dies, as
it does in the majority of instances, the hematocele is absorbed
and recovery follows.
Pathological Anatomy.-Some idea of the size of the tumor
and the resulting changes can be obtained by referring to Figs.
78 and 79. Fig. 78 represents a vertical section through the center
of the pubes and the center of the sacrum; and Fig. 79, a hori-
FIG. 79.
C.D.
EXTRA-PERITONEAL HEMATOCELE.
Transverse pelvic section through rectum, uterus, and bladder, showing lateral dis-
placement of uterus. The same pathological condition as represented in Fig. 78.
zontal section of the same case through the bladder, uterus, and
rectum. The blood is effused into the folds of the right broad
ligament, and the two folds are distended in such a way as
greatly to distort all of the pelvic organs. The effusion in this
case implicates the cellular tissue along the sides of the vagina
and rectum, and carries the cul-de-sac of Douglas to the bottom
of the pelvic floor. If limited to one side the uterus is pushed
to the opposite; if both sides are implicated, the tumor is usually
474
A TEXT-BOOK OF GYNECOLOGY.
much greater on one side than on the other. The two tumors
may unite in front and back of the uterus. In Fig. 78 the fundus
of the uterus is pushed so far to one side that in the vertical
section the entire organ is left undisturbed. The cervix is seen
projecting through the upper part of the vagina. The pressure
upon the rectum and bladder is sometimes greater than in the
intra-peritoneal variety. These illustrations represent very large
effusions; the distortion is correspondingly less when the effu-
sion of blood is not great.
Symptoms. Owing to the fact that the quantity of effusion
is limited by the investing peritoneum, the symptoms are not
usually so marked as in the intra-peritoneal variety. The
patient may have been in perfect health up to the time of the
rupture; if the hematocele is due to a ruptured intra-uterine
pregnancy cyst, the symptoms of this affection may or may not
have preceded the attack. She is first seized with a pain, more
or less acute in character, which is referred to the lower part of
the abdomen. Associated with the pain there is usually a certain
amount of syncope. The degree of pressure upon the bladder
and rectum will depend upon the size and location of the tumor;
it may be very great and give rise to the chief distress resulting
from the accident.
The reactionary symptoms are ordinarily not so marked as in
the intra-peritoneal variety. There is less peritonitis, less fever,
and less abdominal tenderness. If suppuration ensues, the
symptoms do not differ from those attending the disintegration
of an intra-peritoneal tumor.
Upon practising the bimanual, a tumor will be found in one or
both broad ligaments, usually in one only. The uterus, instead
of being in the center or to the front of the tumor, as in the intra-
peritoneal variety, is pushed to one side. The physical char-
acteristics of the tumor do not differ essentially from those of
the intra-peritoneal variety, except that it is at first less fluctuating.
The subsequent changes are much the same. It is at first soft,
becoming more condensed as time progresses, and, in the event
of suppuration, again becoming soft.
In every other respect the course and duration do not differ
materially from intra-peritoneal hematocele.
TREATMENT OF PELVIC HEMATOCELE.
475
TREATMENT OF PELVIC HEMATOCELE.
The physician, when called upon to treat a case of hemato-
cele, should prevent further loss of blood, if it is possible so to
do. He should also direct attention to the shock and syncope
when these symptoms threaten life. The patient should be placed
in bed as quickly as possible, not even waiting to remove the
clothing. Cold applications or an ice-bag over the hypogastric
region should be at once applied, while heat is applied to the
extremities; and, if the shock is at all marked, friction should
be resorted to. If the stomach will tolerate it, stimulants should
be administered in the ordinary way; if, on the contrary, the
stomach is irritable, and nausea and vomiting are persistent,
hypodermic injections of brandy or sulphuric ether may be used.
The symptoms are ordinarily too urgent to allow the use of
vaginal injections, either hot or cold. To obtain the hemostatic
effects of heat would require too much time, and it is hardly safe
to resort to cold injections because of the shock attending their
use. The indicated remedy should be administered internally.
In the event of simple oozing of blood, much good may result
from its use. If, however, the hemorrhage proceeds from a large
vessel, any form of internal medication will be useless.
The foregoing indications are to be employed in the early
treatment of all cases and all varieties of pelvic hematocele. The
subsequent management, after the diagnosis has been made, will
depend upon the quantity of hemorrhage effused, the location of
the tumor, the pressure symptoms, and the advent of sup-
puration.
In extra-peritoneal hemorrhage immediate operative procedures
are rarely called for. Indeed, the usual outcome of these cases,
under expectant treatment, is recovery. In the event of sup-
puration, it is, of course, the duty of the physician to treat the
case as one of pelvic abscess. A primary operation may be
necessary if the effusion be so great as to give rise to intense
suffering because of pressure, or if renewed hemorrhages occur
from time to time. On the other hand, as long as the case pro-
gresses favorably-the tumor gradually becoming smaller, the
pressure symptoms growing less and less severe, the peritonitis
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A TEXT-BOOK OF GYNECOLOGY.
disappearing-the physician's duty is clearly to watch for alarm-
ing developments, and to avert them if it is within his power to
do so.
The treatment of intra-peritoneal hematocele is conducted upon
entirely different principles. No matter what may be the cause
of the effusion-whether the result of extra-uterine pregnancy
or of some of the causes enumerated—there is but one thing to
do if life is threatened, as it usually is by the quantity of blood
poured out, and that is to open the abdomen, seek the bleeding
point, and control the hemorrhage by surgical measures. It
seems to me that there is but one side to the argument in favor
of so doing. It is in thorough harmony with that broad surgical
principle which governs the surgeon in the treatment of hemor-
rhage proceeding from any torn vessel which is accessible.
There is no restricting tissue limiting the quantity of hemorrhage,
as in the extra-peritoneal variety. The capacity of the pelvic and
abdominal cavities is practically unlimited; and it would be quite
as consistent to wait for a severed radial artery to cease bleeding
spontaneously, as to stand by with folded hands, while vessels
equally large are pouring their contents into the free peritoneal
cavity. The technique of abdominal section for this purpose
does not differ from that given for extra-uterine pregnancy.
When an operation is resorted to for the evacuation of the
contents of an hematocele sac, the site of opening will be de-
termined by the location of the tumor. In the majority of in-
stances the vagina is the channel through which the contents are
most easily reached. The relative merits of the vaginal opera-
tion and the abdominal have been the subject of no little dis-
cussion. Rosenwasser (Annals of Gynecology, September, 1889)
decides emphatically in favor of the latter, and in the statistics
collected by him the mortality after laparotomy is 9.9 per cent.;
whereas after vaginal incision it is 10.5 per cent. He maintains
that the danger is not only less in laparotomy, but that the con-
valescence is shorter and the chances of a radical cure greater.
The other advantages insisted upon by him are: the opportunity
afforded to simultaneously remove other lesions that may exist,
the possibility of keeping the sac more aseptic, and the ease with
which the hemorrhage is controlled. Most operators, notwith-
TREATMENT OF PELVIC HEMATOCELE.
477
standing the statistics presented by Rosenwasser, prefer, at least
when the tumor points into the vagina, the vaginal operation.
Operation. The vagina should be washed with an antiseptic
douche and the patient placed in a favorable posture before a good
light. The fluid contents of the sac should be first located by a
trocar guided by the finger. The opening made by the trocar is
enlarged with the scalpel or a pair of scissors. The nozzle of an
irrigator is next gently passed into the sac and the contents
washed away with a weak carbolic solution. The sac is now
carefully packed with strips of iodoform gauze, which will not
only control the hemorrhage but will act as an antiseptic as well.
If the hemorrhage is at all profuse, the gauze can be left within
the cavity for from three to seven days. After its removal a
drainage tube should be inserted, through which the cavity is to
be daily washed with an antiseptic solution. Care should be taken
to keep the free end of the drainage tube closed by means of
a tape. The tube can be held in place in the cavity by pack-
ing loosely about it strips of iodoform gauze; or a T-drainage
tube may be used instead of a straight one. The length of
time required for the complete obliteration of the cavity
will depend upon its size and the thoroughness of drainage.
Usually from one to three weeks elapse before the discharge
entirely ceases.
The technique of abdominal section for pelvic hematocele does
not differ essentially from that given for pelvic abscess. Under
all circumstances an attempt should be made to shut off the hema-
tocele cavity by stitching the walls of the sac to the abdominal
wound. This is not always possible, in which event the sac
should be thoroughly washed out, packed with iodoform gauze,
and a drainage tube left in the free peritoneal cavity; or, if the
contents of the sac are purulent, it may be wise to reclose the
sac from above and make a counter opening through the vagina,
as has been done by Mundé in one instance. Mundé opened the
abdomen, thinking he had to do with an intra- instead of an
extra-peritoneal effusion.
Pozzi advises, in those instances where the tumor is remote
from the posterior cul-de-sac, and where it projects toward the
abdominal wall, subperitoneal laparotomy. He makes a long
478
A TEXT-BOOK OF GYNECOLOGY.
incision parallel to the crural arch, after which he detaches the
peritoneum as far as the tumor and penetrates the latter with-
out opening into the peritoneal cavity. He then passes the
finger into the cyst, and by combined vaginal and abdominal
touch locates a favorable point through which the drainage tube
can be passed into the vagina. An opening is made at this
point and a cruciform drainage tube introduced. He thus com-
bines vaginal with abdominal drainage.
Burton speaks very highly of the use of electricity in pro-
moting the absorption of hematoceles. He keeps the patient.
quietly in bed and uses a galvanic current with large dispersing
electrodes over the back and front; or the negative pole direct
within the vagina. He begins with a current of ten milliampères,
gradually increasing it to one of fifty milliampères.
Von Strauch advocates evacuation of the hematic tumor if it
does not grow smaller in a month, even though no evidence of
suppuration exists. He prefers the vaginal operation to laparo-
tomy. Credé, strangely enough, advocates rectal section. Kraske
recommends the sacral method.
Therapeutics.
Hamamelis.-Hematocele with dark, venous blood from uterus;
from accidental causes with diffuse, agonizing soreness over
whole abdomen.
China.-Pulse irregular, flickering, imperceptible; ringing
in the ears as of bells; syncope; SKIN COLD AND CLAMMY; un-
consciousness.
Arnica.-Hemorrhage caused by injury, concussion, etc.;
feeling of soreness as from a bruise in the lower abdomen; hemor-
rhage associated with internal bleeding, the blood being bright
red.
Phosphorus.-Hematocele occurring in women subject to
frequent and profuse menorrhagia, the blood pouring out freely
and then ceasing for a time; pain in left ovarian region and
down the inner side of thigh; hemorrhagic diathesis with tend-
ency to blood spitting, bleeding from the nose, and hematuria.
Millefolium.-Uterine hemorrhage with profuse flow of
bright red blood, which is thin; chilliness; congestion of the
TREATMENT OF PELVIC HEMATOCELE.
479
head, face, lungs, heart, etc.; patient is violent and irritable,
even though much prostrated by the loss of blood.
Apis.-Especially useful for promoting absorption; STINGING
BURNING PAINS IN THE PELVIS; burning and soreness when
urinating; cutting in left ovarian region extending to right.
Mercurius. To promote absorption; deep, sore pain in
pelvis; dragging in the loins; chilliness, especially in the evening
after lying down, which is not relieved by warmth; chilliness alter-
nating with heat; PROFUSE PERSPIRATION AT NIGHT WITHOUT
RELIEF.
Arsenicum.-Anxiety, restlessness, and chilliness; cannot
find rest anywhere; changes place continually; emaciation with
anxious expression of face; burning or tensive pain in the ovary;
suppuration with symptoms of pyemia.
Ferrum.-Great erethism of the circulation; alternate red-
ness and paleness of the face; very weak; all symptoms worse at
night, particularly after midnight.
Consult :- Terebinthina, secale, sulphur, kali iod., lachesis,
sabina, ipecacuanha, and nitric acid.
CHAPTER XXXI.
PELVIC ABSCESS.
General Considerations.-Suppuration, as is elsewhere indi-
cated, occurs not infrequently as a sequel of acute pelvic inflam-
mation, especially if the latter is associated with the puerperal
state. The predisposing factors tending to prevent resolution in
acute inflammation and to favor suppuration are:-
Tubercular and scrofulous diatheses;
Depravity of the system because of improper food, environ-
ment, etc.
It occurs much oftener as a sequel of inflammation when the
cellular structure is the tissue chiefly involved, but an effusion
resulting from pelvic peritonitis occasionally suppurates, espe-
cially in septic cases. Abscess of the Fallopian tubes (pyo-
salpinx) and abscess of the ovaries are more appropriately dealt
with in the chapter devoted to the diseases of the appendages;
and suppuration resulting from caries of the bones of the pelvis
and spine, while constituting a form of pelvic abscess, is a sur-
gical rather than a gynecological affection, and is not, therefore,
included in the following description. It should, nevertheless,
not be forgotten that pus having its origin in the lesions speci-
fied may give rise, secondarily, to acute inflammation of the
peritoneum and cellular tissue, which in turn may result in
abscess. This is especially true of pyosalpinx.
•
Pelvic hematocele, from whatever cause, may likewise end in
suppuration.
The abscess cavity is not necessarily in contact with the
uterus, for the periuterine inflammation may involve remote lym-
phatic glands, giving rise to inflammation and suppuration at
distant parts; or, in cellulitis, the inflammation may extend to
distant parts by continuity. In the majority of instances the seat
of suppuration is primarily located between the folds of one or
the other broad ligament, but if the accumulation of pus is very
480
PELVIC ABSCESS.
481
great it may burrow in any direction and to almost any extent.
Skene says:*
* "I have seen three cases in which pus from an
abscess in the broad ligament burrowed outward to the iliac
fossa, and then extended upward to the diaphragm, and in one
it opened through the lung into the large bronchial tube."
Pathology.-Pus within the pelvis may remain indefinitely
without escaping. However, it usually makes its exit in order
of frequency as follows: from above Poupart's ligament;
into the rectum, vagina, or bladder; at the anus, or through
the saphenous openings. Rarely does rupture occur into the
peritoneal cavity, though it may.
The encapsulating wall does not differ essentially from chronic
abscesses elsewhere. As time goes on the transudation products
are transformed into connective tissue of greater or less thick-
ness, which constitutes the abscess wall. The interior of the
sac thus formed is made up of villous or granular eminences,
which consist of "loops of blood-vessels buried in transudation
corpuscles." (Agnew.) The leucocytes which give rise to the
pus are chiefly derived from these vessels, though in certain
localities they are produced in limited numbers by the connective
tissue.
Pus, after it is once formed, burrows in the direction of the
least resistance, and the tissues which exert the greatest resist-
ance are the planes of fascia. The size of the abscess is, there-
fore, limited only by the fascial attachments, and, as we have
seen in the cases cited by Skene, it may dissect up the fascia and
peritoneum as high as the diaphragm. In peritoneal abscesses
the effusion may surround a tube distended with pus so that, in
the event of suppuration, there is a small accumulation of pus
within a greater, the former remaining after the latter is evacu-
ated.
After evacuation the cavity may gradually cease to discharge
and the abscess heal; or it may continue to discharge indefi-
nitely. The obliteration, when it occurs, is due to the formation
of granulation tissue and to the adhesion of opposing surfaces.
Obliteration is impossible without complete drainage, and if the
*❝ Diseases of Women," 1889, p. 557.
1
31
482
A TEXT-BOOK OF GYNECOLOGY.
opening is small, sinuous, or unfavorably located, drainage may
be imperfect.
Should the abscess empty itself into the intestinal canal or the
bladder it is liable to contamination by fecal matter or urine.
This may keep up the suppurative process indefinitely, and in
due time the entire pelvis may become honeycombed.
Symptoms.-The affection, whatever its nature, giving
rise to suppuration, will be attended by symptoms peculiar to
itself. In pre-existing inflammation we shall be confronted by
an inflammatory history; or should the primary cause which
is to result in suppuration be a hematocele, or an extra-uterine
pregnancy, there will usually be a history of shock and collapse,
followed by inflammation. A chill, in most instances, marks the
beginning of suppuration. It may be indistinct, but the patient
will at least complain of chilliness. This is followed by fever,
sweating, and prostration. There is often a throbbing sensation
at the seat of suppuration. The pressure symptoms will depend
upon the site of the tumor-if the rectum or bladder is impli-
cated the functions of one or both are disturbed. Pressure upon
the vessels and nerves extending to the lower limbs may not
only give rise to much pain, but, by retarding the return of
venous blood, to great edema as well. As the disease progresses
symptoms of pyemia, from absorption of pus, often become
marked.
The foregoing is the usual history of the formation of pus
within the pelvis. Symptoms of suppuration may, however, be
entirely wanting. In certain cases there will be, perhaps, a
history of pelvic inflammation, and for some reason the patient
does not convalesce as she should. A local examination in these
cases frequently shows that, instead of becoming absorbed, the
inflammatory tumor remains unchanged, or possibly has increased
in size. Indeed, it may be that it has already undergone disin-
tegration and there is a large quantity of pus present, as is
evidenced by fluctuation, without serious systemic disturbance.
Such an accumulation as this is known as a cold abscess, and
occurs oftener in asthenic patients. When the pus is limited
to the tube or ovaries entire absence of chill, fever, etc., is not
uncommon.
PELVIC ABSCESS.
483
On the other hand, a small accumulation of purulent matter
deep in the pelvis, with no evidences of fluctuation or softening,
may give rise to much general distress. Fluctuation is very
often inappreciable in intra-peritoneal abscesses, though soft
spots can usually be detected per vaginam.
Differentiation.-We are called upon to distinguish pelvic
abscess from the following:-
Nephric and perinephric abscess;
Distention of the Fallopian tubes;
Hematocele ;
Extra-uterine pregnancy;
Ovarian abscess.
Nephric and Perinephric Abscess.-These affections rarely give
rise to an abscess large enough to extend into the pelvis, though
I have seen, in consultation with Dr. W. A. Farnsworth of
Petosky, such a case. A vaginal examination will demonstrate
that the abscess does not originate in the pelvis. The most fre-
quent cause of renal abscesses is an injury, the result of a blow
or other forms of traumatism, or a calculus. It may follow
the administration of cantharides or turpentine. Perinephric
abscess, while occasionally an idiopathic disease, is in most cases
a sequence of suppuration of the kidney itself. When the dis-
tention is at all marked there is discoloration and tenderness
over the corresponding lumbar region. The lumbar muscles
are fixed, tense, and brawny. Finally, an examination of the
urine will usually reveal the presence of pus, or other abnor-
malities of this secretion.
Distention of the Fallopian Tubes.- It is often impossible to
detect slight distention of the tubes. A tumor from this cause
is irregular or ovoid in shape, and usually finds its way into the
retro-uterine space. It is painless in hydrosalpinx, but palpa-
tion gives rise to pain in hemato- and pyosalpinx.
Hematocele.-The classical symptoms of this accident, from
whatever cause, are shock and collapse, followed by the sudden
formation of a tumor. Inflammatory symptoms sooner or later
ensue.
Extra-uterine Pregnancy.-Before rupture there is a unilateral
and obscurely cystic tumor in the region of one of the Fallopian
484
A TEXT-BOOK OF GYNECOLOGY.
tubes (in most instances the primary seat is the Fallopian tube).
Some of the usual signs of pregnancy may be present, though
not infrequently the condition is unsuspected previously to
rupture.
Ovarian Abscess.-A suppurating ovary is rarely larger than a
hen's egg; it is very tender on pressure and lies on one or the
other side of the recto-uterine pouch, to which it is usually at-
tached by adhesions. It may be obscurely fluctuating.
Prognosis. In considering the prognosis there are many
points to be noted. The course and duration will depend
upon the size of the abscess, the character of its contents, its
location, and the nature of its opening, or openings. As regards
the life of the patient much will depend upon her vitality and
powers of endurance. Then, too, recovery may be retarded by
those constitutional taints-scrofulosis, tuberculosis, syphilis, etc.
-which always tend to perpetuate the suppurative process in
whatever part of the body it occurs. While spontaneous cures
often result, it must be confessed that, owing to the inaccessi-
bility of the parts, the condition is one to be dreaded. Modern
surgery, thanks to Lawson Tait, has, however, made it possible
to cure quickly many cases that formerly dragged on until the
patient died from sheer exhaustion.
Treatment.-As soon as suppuration is suspected the
strength of the patient should be sustained by nourishing and
concentrated food, free ventilation, etc. The judicious use of
stimulants is often beneficial. Hepar sulphur, silicea, arsenicum,
and mercurius are the classical remedies in suppuration, and
are to be used both for the purpose of aborting and promoting
the suppurative process.
As regards the surgical treatment there is the greatest diversity
of opinion. A review of the literature of the last ten years
bearing upon the subject is most interesting. As a rule,
the older authors are conservative, whereas the younger men,
with few exceptions, teach, with Lawson Tait, that pus within
the pelvic cavity is always a source of danger and should not
be permitted to make its exit spontaneously. I fully agree
with the latter teaching. To me it seems quite as illogical
to permit pent-up pus within the pelvis to make its own exit
PELVIC ABSCESS.
485
through a route often as circuitous as it is dangerous, as to
permit pus within the pleural cavity to take care of itself. I
am speaking now of those large accumulations of purulent
matter where there is no uncertainty regarding the diagnosis.
In the smaller accumulations deep within the pelvis, or confined
to the Fallopian tubes, the diagnosis may be uncertain, and an
exception to the broad surgical principle of early evacuation,
which applies to abscesses in general, may have to be made.*
I desire to quote, somewhat in detail, from Lawson Tait. He says:
"I had been (previous to 1879), therefore, continually on the lookout
for some means of dealing with pelvic abscesses which would bring
them as satisfactorily within our means of treatment as are collections
of matter in most other parts of the body. This has been furnished
by the wide, free, and successful application of abdominal section for
the treatment of pelvic and abdominal tumors, and I am now able to
give a list of thirty-eight cases, which include the whole of my experi-
ence in the novel proceeding, and in which success has been obtained
far surpassing anything I have yet seen or heard of. In this compari-
son, I am, of course, excluding those cases where pointing of the
abscess in the vagina is evident at an early stage of the case, but even
in these the recovery has always been, in my experience, more pro-
tracted than in the six now to be narrated. In addition to this list,
there are about twenty others in which I have operated from above,
but without opening the peritoneal cavity. These, of course, under
the definition of abdominal section I have adopted, are not to be in-
cluded in the present list; but in every one recovery and cure has
been obtained. Fifty-eight consecutive recoveries, prompt and per-
manent, in such a grave condition, constitute a result of a most satis-
factory kind."
It will be seen by the foregoing that Tait does not prac-
tise opening the abdomen when the abscess points toward the
vagina; nor does he open into the peritoneal cavity when it is
possible to reach the abscess through the abdominal walls with-
*"It may be laid down as a general rule that pus is to be removed as soon as it is
formed. In cases of acute abscess this rule may be considered very nearly absolute.
We have now at our disposal the means by which the serious complications that were
formerly met with as a result of putrefactive changes may be avoided, and the with-
drawal of pus has a very beneficial effect in abating the severity of acute inflammatory
processes."-Howard Marsh, Intern. Encyc. of Surgery," vol. ii, p. 268.
† Op. cit., p. 332.
486
A TEXT-BOOK OF GYNECOLOGY.
out so doing. As I understand his teaching, he reserves abdom-
inal section, when suppuration is evident, for the class of cases in
which there is no tendency for the abscess to open either into
the vagina or outwardly through the abdominal wall; or in which
it has spontaneously opened, but for some reason continues to
discharge indefinitely. That abdominal section has a wide range
of application in these two classes of cases I think there can be
no doubt.
By far the larger number of cases, however, calling for abdom-
inal section previously to the discharge of pus through some one
of the usual channels, are those in which the abscess is the
result of a ruptured ectopic pregnancy cyst. These cases mani-
fest a greater tendency to remain quiescent—at least they do not
point as quickly as do inflammatory abscesses-and the retention
of pus will often give rise to much distress, both local and gen-
eral, before a soft spot is felt either from above or below. I
maintain that in cases of the kind it is no more dangerous to
open the abdomen, empty the abscess of its contents, and stitch
the abscess wall to the abdominal wound, through which it can
be thoroughly drained and cleaned, than it is to reach the pus
cavity through the vagina or rectum; and it is certainly infinitely
more satisfactory to both physician and patient. We should, then,
in all instances open the abscess through the vagina or abdominal
wall when nature clearly indicates these points of exit, reserving
abdominal section for the class of cases which cannot be healed
by more conservative measures.
Just when pus should be evacuated in pelvic suppuration will
necessarily depend upon circumstances, for, as insisted upon by
Thomas, every case is a law unto itself. As a general rule a
reasonable delay is wise. It enables the physician to determine
positively that suppuration has taken place, and in the event of
several suppurating foci the smaller cavities will coalesce into
one. Again, by waiting until the point of exit is indicated, ad-
hesions will have formed, so that there is not so much danger of
opening into the peritoneal cavity. It may be impossible to de-
tect small collections of pus deep in the pelvis, and it would be
extremely hazardous to cut into pelvic tissue through the vagina
for any great depth for the purpose of reaching such collections.
PELVIC ABSCESS.
487
The most obstinate cases of pelvic abscess with which I have had
to deal have been those opening into the rectum. Hence if it is
possible to reach the pus through the vagina or abdominal wall,
it is best to do so.*
The operation is performed through the vagina in the follow-
ing manner: The vagina is previously made as aseptic as is
possible by a 1: 3000 bichlorid douche. The patient is then
anesthetized, placed before a good light in Sims' posture, when
the vagina is again thoroughly washed with bichlorid. If the
point of fluctuation is prominent an incision may be made at
once, either with the scalpel or with scissors. Care must be
observed not to injure the large vessels, ureters, bladder, or rec-
tum. The normal relationship of the parts is usually so altered
as to make it wise first to introduce an aspirator, or an exploring
needle. After the cavity has been located by the needle Mundé
recommends, for the purpose of enlarging the opening, a pair of
sharp-pointed scissors which are pushed into the cavity, the needle
serving as a guide; the blades are then separated, when the
pus will gush forth. The opening can be further enlarged with-
out injuring the parts by the method of Hilton, which consists
of the introduction and withdrawal of some blunt expanding
instrument—an ordinary pair of catch forceps, or a uterine dila-
tor. After the evacuation, the cavity is washed with a weak
solution of bichlorid (1: 10,000); or, if there is very much
fetor, with a solution of permanganate of potash. The finger
should be carried into the sac and all sulci freely broken down.
If the granulations are marked they should be destroyed, either
with the finger nail or a blunt curette. The abscess cavity is
again washed, and, if the parts are readily accessible, the tincture
of iodin may be applied to the pyogenic membrane. A rubber
drainage tube is then introduced, through which the cavity can
be irrigated several times a day with a weak permanganate solu-
tion. The tube may be held in place by loosely packing the
vagina with iodoform gauze. It is gradually withdrawn as the
abscess closes, and, finally, entirely removed.
* Segond recommends vaginal hysterectomy for pelvic suppuration, and Terrillon
trephines the pelvis at the most dependent part of the abscess.-Annual of Universal
Medical Sciences, 1892.
488
A TEXT-BOOK OF GYNECOLOGY.
Careful watching is required during the healing process. The
parts must be kept absolutely sweet and clean, and the opening
should not be permitted to close until the sac is entirely obliter-
ated. It may be kept open for a few days after the tube is re-
moved by passing through it a strip of gauze.*
Closure of the Sac and Treatment of Sinuses.-Before
abdominal section is resorted to, various expedients are recom-
mended for this purpose. If the abscess has opened externally
and the sinus is sufficiently large to afford free drainage, an
attempt may be made to close the sac by keeping it thoroughly
clean and injecting it twice or three times a week with tincture
of iodin. Failing in this, the opening should be enlarged, and,
if possible, the sac packed with iodoform gauze. The same
measures may be tried from below if the abscess has opened
into the vagina, and, in a limited number of cases, a cure can
be accomplished. When, however, an abscess has opened ex-
ternally and continues to discharge indefinitely in spite of all
efforts to heal it from above, a counter opening should be made
through the vagina. This may be accomplished by passing a
strong probe through the external sinus and causing its tip to im-
pinge against one of the vaginal fornices. This is cut down upon
and, if possible, a perforated rubber tube is drawn from above
through the opening thus made into the vagina. The parts can
now be thoroughly washed and injected, and the healing pro-
moted. The tube is to be gradually drawn into the vagina as
the sac closes from above.
In the event of fecal contamination care must be observed in
* Dr. G. H. Lyman has placed on record (Trans. Am. Gyn. Soc., vol. vi), seven-
teen cases of pelvic abscess treated by the aspirator. The results were as follows:
Io cures; 4 not benefited; 2 injured; I improved only. The cavity was simply
emptied and left without being washed or injected. In commenting upon these re-
sults Maury (“ Am. Sys. of Gyn.,” vol. 1, p. 731) justly says: “The results reported are
probably too favorable, for the following reasons: one of these cases, as shown by the
report, was discharged from the hospital while remnants of exudation were still
recognized within the pelvis. Some remained only a few days after the operation,
one being discharged five days after aspiration, another thirteen, another fourteen
days. The report cannot, therefore, be considered conclusive in regard to the ques-
tion of cure." Personally, I use the aspirator in these cases for diagnostic purposes
only.
PELVIC ABSCESS.
489
making this counter opening. In Case LXVI, the probe passed
into the intestine instead of into the abscess, and, had I cut down
upon the probe through the vagina, I would have created an
entero-vaginal fistula.
Cases Illustrating Technique of Abdominal Section.
CASE LXVI.—Pelvic Abscess and Fecal Fistula following Laparotomy Cured by
Abdominal Section.-Patient æt. 28, married, and referred to me by Dr. A. B. Cornell
of Kalamazoo. A large abscess followed an abdominal section made for the purpose
of removing a suppurating dermoid cyst of the right side and a pyosalpinx of the left.
The operation was a most difficult one, the numerous adhesions necessitating the appli-
cation of many ligatures within the abdomen.
The patient rallied from the primary operation, and for the first two weeks did
remarkably well. Owing to the large quantity of pus which had escaped into the
peritoneal cavity, the drainage tube was not removed until the end of the fourth day.
As a result, a sinuous tract was left which, instead of healing, continued to discharge
pus, and this so contaminated the abdominal wound that a parietal abscess formed.
Notwithstanding these several complications, the patient continued to gain in strength
and in four weeks was up and about. The sinus continued, however, to discharge
variable quantities of pus, and evidently there was a large pus-cavity on the right
side extending nearly to the umbilicus. At the end of six weeks chloroform was
given, the sinus enlarged, and an effort made to carry a drainage tube to its bottom,
but owing to the pain excited by the tube the patient could not tolerate it. At the
end of twelve weeks the discharge had diminished but little, and further exploration
seemed imperative. Accordingly, on April 21st preparations for any emergency were
made, and the abdomen reopened. The sinus led to the base of the right broad
ligament down to the colon, and the accumulation of pus had dissected up what was
left of the posterior layer of the right ligament, which, together with the peritoneal
investment, formed the abscess wall. At the very bottom of the abscess two ligatures
were found which had failed to become encysted. This was undoubtedly the secret
of the persistent discharge, and in due time the ligatures would probably have found
their way to the surface. The next step in the operation was to stitch the abscess
wall to the lower angle of the abdominal wound. A rubber drainage tube was
carried to the bottom of the abscess cavity and a glass tube into the Douglas pouch,
after which the abdominal cavity was washed and the abdomen closed in the usual way.
The patient again quickly rallied, and promised a speedy convalescence, when on
the fifth day she began to have a fecal discharge through the sinus leading to the
abscess. This discharge increased in quantity for ten days, notwithstanding the fact
that the bowels were moved every other day by the aid of enemata. It then began
to decrease, but fecal contamination prevented the abscess from healing entirely, and,
conversely, the pus so contaminated the fecal opening as to prevent its spontaneous
closure. A probe passed from above would insinuate itself into the bowel instead of
into the abscess cavity, and I therefore did not dare to make a counter vaginal open-
ing. Various expedients were tried during the next twelve months to cure the abscess
and close the fecal fistula, but in vain. I finally made an extensive dissection of the
cicatrix, carefully removed the adhered intestine from the abdominal wall, and closed
the opening into it by a series of Lambert sutures. I then passed a drainage tube into
the abscess and closed the abdominal wound. On the fourth day fecal matter again
490
A TEXT-BOOK OF GYNECOLOGY.
escaped externally, but it gradually grew less in quantity, and in about two months
ceased entirely. A small pin-head opening persisted for about two months longer,
but finally healed perfectly. The discharging sinus closed very quickly after the fecal
matter was kept out of it. The patient is now (twelve months later) perfectly well.
CASE LXVII.—Abscess of the Left Ovary and Broad Ligament following Puer-
peral Cellulitis and Peritonitis; Laparatomy; Recovery.—Mrs.
æt. 28, mar-
ried; patient of Dr. D. M. Nottingham's, of Lansing. She presented herself at
my clinic on May 23, 1887, and gave the following history: During her eleven years
of marriage she had been twice pregnant, the first pregnancy resulting in a miscar-
riage at the seventh month because of a strain. Her second child was born thirteen
months later, from the birth of which she dates her present trouble. She did not get
up well from this confinement. When her baby was four weeks old she was taken
with a severe attack of pelvic inflammation, which continued for two months. She fin-
ally recovered, and for the following three or four years was fairly, though not entirely,
well. She then had another severe attack of inflammation, brought on by undue ex-
posure during the menstrual period, and for the succeeding three years suffered con-
stantly from pressure pains in and about the pelvis. Following this she was stricken
with typhoid fever (September, 1886), since which time she has had most excruciating
pain in the pelvis, especially in the left ovarian region, which is of a burning, stinging
character. There is also a sharp, cutting pain in the corresponding hip and down the
limbs. Excessive menstruation, occurring at first every six weeks, dates from the
birth of her last child; but the intervals gradually grew shorter until the inter-men-
strual period was but ten days. The flow was always attended by much pain, which
began several days before its onset and gradually increased in severity.
The patient upon coming to the hospital was almost bloodless from the excessive
menstrual discharge. She had been compelled to remain in bed almost constantly since
her last illness in September. I found, upon making a local examination, the pelvic
organs all matted together, as a result of the previous inflammatory attacks. There
was much tenderness, especially on the left side; the uterus was retroflexed and per-
fectly immobile; the roof of the pelvis was as unyielding as a board. I could detect
no evidence of fluctuation, but was positive that pus existed in some part of the pelvis,
for the pyemic symptoms were very marked. I did not do then, as I should now do
under similar circumstances-operate at once,—but tried for nine months to make an
abdominal section unnecessary. The uterus was curetted for the purpose of con-
trolling the hemorrhage, but the operation did no good, and like results attended con-
stitutional and the routine local treatment. Accordingly, on February 23 of the fol-
lowing year I opened the abdomen. The exploring finger came in contact with a
mass which was hard, rigid, and completely distorted the left broad ligament. The
left ovary and tube could not be distinguished, but the fundus of the uterus was
indistinctly outlined in the posterior cul-de-sac. A soft point was felt at the upper
part of the mass on the left side, into which an aspirating needle was thrust, but the
contents of the sac were too thick to be drawn off through the needle. I therefore
opened the sac with a scalpel, and a teacupful of exceedingly offensive pus poured
forth. I then enlarged the opening and found that the abscess included the ovary,
which was nothing more than a shell. It was impossible to stitch the abscess
walls to the parietal opening, so I broke down and removed its posterior wall,
scraped away the secreting membrane, and applied to the entire raw surface, after
thoroughly washing the abdominal cavity with sterilized water, tincture of iodin.
PELVIC ABSCESS.
49I
I then dug the right tube and ovary from inflammatory exudates, tied and removed
them. A glass drainage tube was inserted and the abdomen closed. The tube was
left in for five days. The patient made a somewhat tedious convalescence, but the
improvement was finally of the most decided character. In four months' time she was
doing her own work, including her washing, and had gained amazingly in flesh.
and
CASE LXVIII.—Pelvic Abscess following Hematocele; Laparotomy; Recovery.
Mrs. II—, aged twenty-nine, was married at eighteen, had a child within the year,
has never been pregnant since. . . The history given to me was that about nine weeks
previously, when driving in an open carriage with her husband, on a very cold day, and
during a menstrual period, she was suddenly attacked with a violent pelvic pain, and
coincidently with it the discharge ceased. The pain had continued ever since, and had
of late increased in severity. Menstruation had occurred at two irregular intervals
since the beginning of her illness with great profuseness, and during these periods her
pain had been much easier. A pelvic tumor had been discovered by Dr. Millington
some weeks before my visit, and this he had regarded as an effusion of blood. She
had suffered for about three weeks before I saw her from night-sweats, almost constant
sickness, utter loss of appetite, intense thirst, with various other symptoms of pro-
nounced hectic. The tumor, when I examined it, involved all of the pelvic organs in
a fixed mass of cartilaginous hardness, with the uterus imbedded in it; the bladder
spread over it in front, and the rectum was encircled by a ring of hard effusion. The
mass could be felt about the pelvis as a round and non-fluctuating tumor, with intes-
tine in front of it. The patient had reached almost the final stage of exhaustion and
emaciation. There was no difficulty in diagnosing the case as one of suppurating
hematocele. With Dr. Blackford's concurrence, we had her removed to Birmingham,
and on the 21st I opened the abdomen and found matters quite as I had anticipated.
The posterior layer of broad ligament was lifted completely up out of the pelvis, and
so was the anterior layer, as far as I could make out; at least, the only structure I
could identify was the base of the bladder, and that seemed to form the anterior
boundary of the tumor. From this point it spread backward, on a level with the brim
of the true pelvis, and its posterior boundary was the bifurcation of the aorta. The
contents were clearly fluid, and therefore I tapped it with an aspirator needle, and
evacuated about half a quart-bottleful of curdy, blood-colored pus. I then laid the
cyst open from the point of puncture, in the direction from before backward, and
found its floor to consist of a thick layer of laminated clot, hard and rigid. I could
make out the uterus rising out of this mass, but I could not discover the rectum.
I stitched the edge of the opening into the abscess to the edges of the parietal
wound, and then enclosed the rest of the peritoneal opening, and fastened in a wide
drainage tube of glass. After the operation the patient's temperature never rose above
37° C., she had no more night-sweats nor sickness, and her appetite was really keen on
the third day. A small-sized wire drainage tube replaced the glass one on the twelfth
day, as the discharge had become healthily purulent and free from clot débris. The
smaller drainage tube was removed on the fifteenth day after the operation, and on the
twenty-fourth the sinus was quite healed, she had gained greatly in flesh and color,
was able to walk about, and on the twenty-seventh day she went home perfectly
well, the uterus, however, being still quite fixed, as I expect it will remain for years.
I have repeatedly seen this patient since the time of operation, and her health remains
perfect to this day.-Lawson Tait.
CHAPTER XXXII.
DISEASES OF THE URETHRA AND BLADDER.
ACUTE URETHRITIS AND CYSTITIS.
ACUTE UREthritis.
General Considerations.—In treating of vaginitis I dwelt
upon the uncertainty of differentiating between the specific and
non-specific forms of inflammation attacking the genital and
urinary tracts. It was there stated that specific vaginitis oftener
involves the urethra than does non-specific, and this is un-
doubtedly true. Nevertheless, acute urethritis may occur inde-
pendently of gonorrheal infection. In both forms of inflammation
the patient will complain of a burning pain in the urethra, more
or less severe, which is greatly aggravated by urination. It is,
however, claimed by Skene that the history of the two affections
is quite different. Simple urethritis," he says, "comes on
gradually and is often preceded by symptoms of uterine or
vesical disease, while the gonorrheal variety comes on rather
abruptly and is preceded or attended by acute vaginitis or vul-
vitis." A microscopic examination usually reveals gonococci
in the discharge of specific urethritis.*
(6
In both forms of inflammation painful spasmodic contractions
of the canal, interfering with or preventing the flow of urine,
are of frequent occurrence.
The mucous membrane, upon physical examination, will be
found red, congested, and exceedingly sensitive. By using an
endoscope or speculum, mucus or pus will be found between its
folds.
ACUTE CYSTITIS.
Frequency.—Acute cystitis in women is a disease probably
more frequent than the student is led to infer from the teachings
of many of our more prominent gynecological authorities.
*v. pp. 74 and 381.
492
ACUTE CYSTITIS.
493
While it is a lesion not confined to women, yet the anatomical
peculiarities of the female bladder are such as to make it more
liable to inflammatory attacks than is the male bladder. The
uterus and annexa, posteriorly and superiorly, frequently
implicate it in a reflex way or by direct transmission; while the
vagina is lined with a mucous membrane often the seat of specific
or non-specific inflammation, which is readily conveyed through
the urethra to the bladder. Again, the numerous injuries follow-
ing in the train of parturition not infrequently end in inflam-
mation of the organ.
Pathology. In its pathology there is nothing peculiar or
remarkable. The changes will vary somewhat according to the
severity and violence of the attack, yet they are not unlike those
found in inflammation attacking any mucous surface.
At the outset the existing hyperemia gives a bright red appear-
ance to the membrane, which soon becomes swollen and relaxed.
At certain points the epithelium will be destroyed, particularly
at the summit of the ruga, between the folds of which, and in
the sulci, pus is usually found. These, in brief, are the ordinary
changes incident to the disease. Occasionally the destructive
process is much more decided, especially in certain cases follow-
ing prolonged distention. All of the mucous
mucous and sub-
mucous tissues may become involved, the entire lining membrane
of the bladder being shed or cast off en masse; usually this occurs
only in post-puerperal cases, at which time the general conges-
tion and succulency of all the pelvic organs favors extensive
destruction. During confinement, pressure upon the neck of
the bladder or upon the urethra causes tumefaction of the parts
and consequent obstruction. As a result, the urine may be
retained for an indefinite length of time, the dribbling from the
over-distended organ deceiving both nurse and physician, until
the excessive intra-vesical pressure cuts off the capillary circu-
lation from the mucous membrane, causing, in due time, its
partial or complete death, after which it is exfoliated and cast
off. This, at least, is the explanation given by Liston, and it
seems a very probable one. Skene suggests that where the dis-
tention has been sufficiently great to cause separation, the death
of tissue may be due to excessive congestion following sudden
494
A TEXT-BOOK OF GYNECOLOGY.
emptying of the organ. The succeeding changes are those of
chronic cystitis.
Etiology. The etiological factors of acute cystitis are both
numerous and varied, some having already been suggested.
There is not a consensus of opinion as to whether or not it ever
occurs as an idiopathic affection. While not as profoundly im-
pressed by the causes giving rise to general pelvic congestion
as are the uterus and ovaries, yet the blood supply of all of the
pelvic viscera is derived from the same general source, and it
therefore requires no great stretch of the imagination to believe
that cold or undue exposure may excite cystitis. However, in
the vast majority of instances, the trouble can be traced to un-
mistakable exciting causes, though it is reasonable to believe
that women of scrofulous tendencies are more liable to have
catarrh of the bladder, when exciting causes exist, than are those
free from constitutional bias. At any rate, the slightest irrita-
tion or exposure will, in some women, set up congestion or actual
inflammation of the bladder.
Of the various exciting causes none is more important than
parturition, to the improper conduct of which many a woman.
owes her invalid life. Cystitis is here produced either by undue
and prolonged pressure of the fetal head, by retention of urine, or
by septic invasion-all preventable causes in most instances. Of
those originating from within the body, abnormalities of the urine
are to be noted, yet, in a bladder perfectly healthy, it is difficult to
comprehend any unnatural condition of the urine sufficient to
excite an inflammation. Unfortunately, many bladders are not
perfectly healthy, being at all times more or less congested or
abraded, a condition that may be transformed into true inflam-
mation by urine loaded with lithates or with pus. Abnormal
urine is oftener the result than the cause of cystitis. Of those
originating from without the body we may enumerate traumatism,
the introduction of foreign bodies by masturbators, uncleanly
or unskillful catheterization, and unnatural or violent coitus.
The bladder, like all other organs of the body, is predisposed
to inflammation by any condition causing a chronic congestion.
Disorders of the heart, liver, and kidneys act in this way. In
acute exanthematous diseases the vesical mucous membrane
ACUTE CYSTITIS.
495
may sympathize with the tegumentary tissues, and even become
seriously involved. Certain drugs—cantharis, terebinthina, can-
nabis sativa, etc.-possess the power, in doses sufficiently large,
to inflame the bladder. As has been intimated under the head of
pathology, diseases of contiguous organs may extend to the
bladder. Urethritis, especially specific, frequently implicates the
organ by extension of inflammation.
Symptoms. Acute cystitis, while often giving rise to symp-
toms most decided and pronounced, does not affect the organism
as does chronic cystitis. In the simple types of catarrh the
symptoms appear suddenly, there being a sensation of distress
and weight back of the pubes, with increased frequency of mic-
turition, which is more or less painful. The degree of tenesmus
varies according to the extent to which the vesical neck is impli-
cated. The urine is but little changed, is slightly acid or neutral
in reaction, and may be clouded. The specific gravity remains
normal, and if there is a sediment it will contain an increased
quantity of leucocytes, with or without phosphatic crystals.
Even when acute cystitis is purulent from the onset, the
general disturbance may not be very great, except, as Richard-
son observes, in those attacks due to bacterial invasion following
labor. In these cases the onset is announced by a severe rigor,
followed by a temperature ranging from normal in the morning
to 103° or 104° in the evening. The hypogastrium may become
very tender and the dysuria and tenesmus unendurable. In the
purulent form the changes of the urine are more decided, it being
ammoniacal, invariably alkaline, and containing pus and blood in
varying proportions. The sediment contains, besides the blood-
and pus-corpuscles, triple phosphate crystals, bladder epithelium,
and bacteria.
Those forms of acute cystitis which occur as a local expres-
sion of severe constitutional disease-diphtheria, erysipelas, and
croup-are always of serious import, and demand of the atten-
dant prompt and vigilant treatment.
Differentiation.-There may be some difficulty in differentiat-
ing acute cystitis from acute urethritis, especially if the subjective
symptoms alone are relied upon. Severe pain in the latter
affection does not precede, and lasts but a short time after,
496
A TEXT-BOOK OF GYNECOLOGY.
micturition. It is also said that there is an oozing of pus more.
or less continuously from the urethra in urethritis; whereas in
cystitis pus escapes only during micturition, and the urine which
escapes last is more cloudy than that first discharged. The un-
certainty of this test is, to my mind at least, very great.
When the pus comes from the kidneys there will be more al-
bumin than can be accounted for by the total quantity of the pus
and blood present in the urine. Again, in renal disease the tube-
casts, the absence of pain during micturition and in the
region of the bladder, ought to direct attention to the kidneys.
In prolapsus uteri there may be frequent urination not unlike
that produced by cystitis, but the normal condition of the urine,
and the aggravation arising from standing or walking, will at
least suggest the cause of the trouble.
The dysuria arising from vesical neuroses is characterized by its
sudden appearance as well as by its sudden disappearance. If
there is any change in the character of the urinary secretion it is
but temporary. In adhesions of the bladder the desire to empty
the organ is not urgent except when it becomes partially dis-
tended. The urine remains unchanged. Fissure of the bladder
can be positively determined only by the use of the endoscope.
Treatment.—In the treatment of acute cystitis and urethritis
prophylaxis is of the first importance, and the various causes
enumerated should be carefully avoided or removed. Unclean
catheters should be banished from the lying-in and operating
room. I now use almost exclusively Kusner's glass catheter, the
proper care of which is given in the chapter devoted to antisepsis.
Unless absolutely necessary, catheterism after operations should
not be resorted to. Even after abdominal section the patient is
usually able to urinate with much less distress than is caused by
the introduction of the instrument, and experience has fully de-
monstrated the harmlessness of permitting healthy urine to come
in contact with plastic operations if antiseptic injections are used.
With the possible exception of vesical fistula, I no longer draw
the urine after operations, except in those cases where swelling
and tumefaction have temporarily occluded the urethra, or where,
owing to some peculiarity of the patient, she cannot urinate while
in the recumbent posture.
ACUTE CYSTITIS.
497
On the other hand, catheterism is frequently called for in
post-puerperal conditions, and the importance and necessity of
examining the bladder carefully during the first few days of the
puerperium should be indelibly impressed upon the mind of the
student. A very large proportion of the cases of cystitis date
from childbirth, and in no instance should the statement of either
nurse or patient be relied upon as regards the passage of urine,
especially if there be dribbling. In consultation with Dr. J. W.
Wheelock of Bancroft, Mich., I once saw a parturient woman,
moribund with symptoms of septicemia and uremia, whose
bladder reached the umbilicus, giving to the abdomen, so great
was the distention, the appearance of tympanitic enlargement.
Catheterization rewarded us with two large-sized pots de chambre
full of urine, the distention having been overlooked by two
well-known physicians who had preceded Dr. Wheelock in the
case.
Abnormalities of the urine, when they exist, should be cor-
rected, and hemorrhoids, fissures, or any disease of neighboring
organs should be removed. Necessitas tollenda causa applies to
the treatment of cystitis quite as much as it does to the treatment
of any other inflammation.
During the attack, rest, more or less absolute, should be in-
sisted upon. The recumbent posture should be maintained, and
if the vesical pain and tenesmus are very great, much relief may
be afforded by the hot sitz bath or vaginal douche. If the
urethra is the part chiefly implicated, a stream of warm water
falling upon the external meatus for ten or fifteen minutes and
repeated three or four times a day is often most useful. Con-
centrated and irritating urine can be diluted by permitting the
patient to drink freely of either water, milk, or some mucilagin-
ous fluid. The diet should be unstimulating and bland, milk
being the best of all articles. These precautions, in conjunction
with the indicated remedy, will, in probably the larger proportion
of cases of acute aseptic inflammation accomplish a cure. Aco-
nite, belladonna, cantharis, cannabis sativa, chimaphila, mer-
curius cor., and arsenicum comprise a list of remedies frequently
useful.
After the duration of a week or longer without manifest im-
32
498
A TEXT-BOOK OF GYNECOLOGY.
provement, the disease will have assumed a subacute or chronic
character, and may demand more direct local medication, the
method of applying which, together with the therapeutic indi-
cations, is given in the succeeding section.
CHRONIC URETHRITIS AND CYSTITIS.
Chronic urethritis is occasionally met with as a result of some
distortion of the urethra-dilatation, prolapse, or backward dis-
placement—the latter condition arising from contraction of the
utero-sacral ligaments. It is oftener, however, the sequel of
acute inflammation and may be exceedingly obstinate and per-
sistent in its course.
The symptoms have to do largely with the function of mic-
turition, there being more or less pain and tenesmus, with a slight
discharge of pus. The pus will be washed away by the urine
first passed, that left behind, if drawn off subsequently, being
comparatively free from sediment. The disease rarely exists for
any length of time without sooner or later implicating the
bladder.
Chronic Cystitis.-The mucous membrane undergoes the
usual changes of chronic inflammation, assuming a muddy gray
color. The epithelium is freely shed and may be necrosed and
ulcerated; or the membrane may be cast off en masse, as
in the acute variety. The ulceration may extend into, and even
perforate, the walls of the bladder. Hyperplasia sometimes takes
place at the seat of ulceration, resulting in the development of
polypoid material (Skene). As time goes on the sub-mucous
intermuscular tissue becomes thickened-partly because of the
extension of inflammation and partly because of the vesical
tenesmus. When the disease extends to the muscular parietes
it is known as interstitial cystitis; if the peritoneal coat is impli-
cated, as epi-or peri-cystitis.
Etiology. The same causes giving rise to the acute form of
inflammation may, when acting less violently, set up the chronic
form. Indeed, it is a frequent sequel of acute cystitis. Other
causes are: foreign bodies, calculi, tuberculosis, cancer, paralysis,
displacements of the uterus, perivesical inflammation, and irri-
tating internal medicines.
CHRONIC URETHRITIS AND CYSTITIS.
499
Symptoms. These are local and constitutional. The local
symptoms are caused by the contact of urine with the inflamed
walls. There is a desire to urinate as soon as a slight accumula-
tion of the secretion occurs, micturition being attended with pain,
tenesmus, and, frequently, spasm. The character of the urine is
variable, depending upon the extent and chronicity of the disease.
Its specific gravity is usually low, and it contains pus, epithelium,
mucus, and, not infrequently, blood-cells. These various abnor-
mal elements give rise upon standing to an albuminous, ropy
deposit, more or less abundant. It speedily becomes alkaline
and phosphatic and possesses a fetid, ammoniacal odor.
The system is always more or less impressed by the persist-
ence of the disease, sometimes most profoundly so. As
time goes on, hypertrophy of the neck of the bladder ensues,
which makes complete evacuation impossible. The urine thus
retained becomes stale and increases the irritation. A certain
quantity of pus and urinary elements are absorbed, so that the
patient soon shows signs of cachexia and chronic septicemia.
In the worst cases of ulceration there is infiltration of urine into
and through the bladder walls, which occasionally terminates in
abscess and serious pelvic inflammation; or the disease may
implicate the opening of the ureters, giving rise to partial occlu-
sion, the obstruction terminating in distention of these canals
together with the pelves of the kidneys. The kidneys may be-
come disorganized and suppurate, death occurring from pyemia
and uremic poisoning.
Even in the milder forms of chronic cystitis the patient shows
the effect of the disease in various ways. She is constantly
broken of her rest, being compelled to get up during the night
from five to twenty times for the purpose of emptying the blad-
der. This in itself soon tells upon her. Nutrition is always
more or less affected, the appetite is impaired, and the counte-
nance is indicative of suffering. Nervous symptoms of various
kinds sooner or later supervene.
Treatment. The general measures recommended in acute
urethritis and cystitis are to be observed in the treatment of the
chronic forms of inflammation. Diluent drinks-gum-arabic
water, flaxseed tea, and slippery-elm water-are useful for chang-
500
A TEXT-BOOK OF GYNECOLOGY.
ing the character of the urine. Drinking freely of some of the
mineral waters for the purpose of diluting the urine is also bene-
ficial. The waters most used for this purpose are the Vichy,
Bethesda, Waukeshaw, and Buffalo Lithia. The diet should be
nutritious but bland, it being best to eschew alcoholic beverages,
spices, asparagus, etc.
As soon as the evidences of pus become marked, in either
urethritis or cystitis, the parts should be irrigated at least once
or twice a day. Skene has devised a reflux catheter for irrigat-
ing the urethra, which is shown in Fig. 80. With this instru-
ment the urethra can be douched with water as hot as the
patient can bear it and as often as necessary. It should only be
passed as far as the neck of the bladder. The water used may
be medicated with hydrastis, calendula, boracic, or carbolic acid.
Skene has also devised a most simple instrument for washing
FIG. 80.

G. TIEMANN & CO
Reflux CatheTER. (Skene.)
out the bladder. It consists of a small glass funnel to which is
attached a piece of rubber tubing eighteen inches or two feet in
length. The distal end of the tubing is connected with a soft
rubber catheter. I have substituted the glass for the rubber
instrument. The catheter is introduced into the bladder,
and the urine is drawn off through it-enough, however, being
left behind to fill the tubing and prevent the entrance of air.
The solution to be used is now poured into the funnel, which is
raised sufficiently high to force the water into the bladder. After
the bladder contains as much of the fluid as the patient can
tolerate without pain, the funnel is again lowered and the fluid
drained off. This can be repeated until the water returns clear.
Care should always be taken to prevent air from entering the
bladder.
If the urethral tenderness is very great, before introducing
CHRONIC URETHRITIS AND CYSTITIS.
501
the catheter, I apply to the urethra, by means of an ordinary
dropper, a few drops of an eight per cent. solution of cocain.
The choice of fluids to be used in washing the bladder should
be governed by circumstances. There is nothing better than a
two per cent. carbolic solution to prepare the way for a medica-
ment. Skene prefers a solution of borax or common table salt
(one tablespoonful to a quart), and Mundé recommends a tepid
I: 1000 boracic acid solution. After the bladder is thoroughly
washed in this way I add to the last pint of water injected the
medicament, if one is indicated, and instruct the patient to retain
three or four ounces of it for some minutes, so that it may come
in contact with the entire mucous membrane. The remedies
oftenest used by me for local medication are calendula and hy-
drastis: calendula if there is a great deal of pus, or evidences of
' ulceration; hydrastis, if the deposit is composed largely of tena-
cious mucus. The strength of each should be about 1:20.
If good is to be obtained from this treatment, it must be em-
ployed at least once or twice a day and persisted in for some time.
If the bladder is washed but once or twice a week the improve-
ment will be very slow, hence the nurse or attendant (and any
intelligent nurse can do it) should make the treatment, under the
direction of the physician. The carefully selected internal
remedy is, of course, to be given in conjunction with the local
measures recommended.
Chronic cystitis, under the most favorable conditions, usually
runs an obstinate course, and, in spite of the foregoing treatment
faithfully and persistently carried out failures will every now and
then result. The great difficulty to contend with is the constant
contact of irritating urine with the inflamed bladder walls, thus
making physiological rest impossible. There is but one way to
overcome this difficulty, and that is to make an opening through
the vesico-vaginal septum sufficiently large to permit the
urine to drain into the vagina as soon as it enters the bladder.
This operation is known as colpocystotomy. It is not difficult
to perform and there is nothing more simple than closing the
artificial fistula after the cystitis is cured. I have opened
the bladder many times for chronic inflammation, and, except in
one instance, have never failed to close the opening on the
502
A TEXT-BOOK OF GYNECOLOGY.
first attempt. In the instance referred to the light was wretch-
edly bad, and undoubtedly I coaptated an unvivified surface.
This patient was brought to me by Dr. J. W. Ritter of Dexter,
Mich. A second operation has not yet been made.
In a given case of chronic cystitis I proceed, then, as follows:
An attempt is first made to cure the disease by the measures which
have been recommended. If these fail after a thorough trial, or
if the local treatment is impracticable because of the very great
pain which it induces, the patient is given an anesthetic, and an
exploration made. Should there be found sufficient urethral
disease-fissure, ulcer, angioma, etc.-to keep up the cystitis by
the dysuria and tenesmus excited, and the bladder changes are
not great, the disease is removed and the urethra dilated with
some expanding instrument (Pratt's urethral speculum is excel-
lent for the purpose) with the hope of relieving the tenesmus
and curing the cystitis. I have succeeded in curing several
cases in this way. If this procedure fail, or if the hypertrophy
of the bladder walls be already marked, I then proceed to per-
form colpocystotomy.
Colpocystotomy. The patient is placed in the Sims posture
and a good-sized male sound is introduced into the bladder, the
point being made to impinge upon the trigonum vesica-midway
between the neck of the bladder and the cervix uteri, in the
median line. The point of the sound is cut down upon by means
of a scalpel, when it is removed and the edges of the wound
separated by two tenacula hooked into either side through the
vagina. One blade of a pair of angular scissors is now passed
into the opening, which is enlarged to the extent of an inch.
Finally, the mucous membrane of the bladder is stitched to that
of the vagina by a running interlooped catgut suture. Unless
this last precaution is taken it is impossible to keep the wound
from healing; even with it, the opening will close unless it is
dilated with the finger once or twice a day for the first ten days.
The bladder can now be gotten at for proper treatment, and
washed through both the urethra and the artificial opening. The
relief afforded is most remarkable, and the patient usually begins
to gain at once. I have had patients gain thirty pounds in four
months' time following the operation. They begin to eat almost
DISEASES OF THE URETHRA AND BLADDER.
503
immediately, are no longer compelled to get up several times dur-
ing the night in order to empty the bladder, and the symptoms of
septicemia disappear. There is, to be sure, more or less inconven-
ience and distress caused by the constant dribbling of urine into
the vagina and its contact with the external organs. This can be
largely overcome by frequent washings, and the application of
some of the protective ointments recommended for pruritus
vulvæ. I never have succeeded in successfully fitting any of the
cup pessaries devised for the purpose of conveying the urine
from the fistula into a urinal attached to the limb.
The fistula should not be closed until the inflammation and
ulceration are entirely cured. The length of time required to
accomplish this is from three to eighteen months. It is a most
remarkable fact-one that affords some idea of the suffering
incident to cystitis-that patients who have undergone the oper-
ation, notwithstanding that they are constantly wet from the
dribbling of urine, are usually loath to have the opening
closed, so great is the relief experienced. The technique of the
operation for closing it does not differ from that required for
fistulæ produced by other causes.
Therapeutics.
Cantharis.—TENESMUS VESICE; constant desire to urinate, pass-
ing only a few drops at a time, often mixed with blood; stinging
and burning pains in the region of the bladder before and after
micturition, or cutting pains from the kidneys to the bladder;
abdomen distended and painful to contact, especially in the re-
gion of the bladder.
Apis mel.-Great irritation at neck of bladder with frequent
and burning urination; frequent desire with passage of only a
few drops; BURNING AND STINGING IN THE URETHRA; useful in
cystitis and urethritis caused by cantharis; bladder symptoms
are aggravated by drinking water. "It seems as if the sight of
water brings about a constriction of the sphincter muscle."—
Farrington.
Aconite.-High fever; restlessness; constant urging, yet fear-
ful of evacuating urine on account of painfulness of the act;
micturition difficult, sometimes only drop by drop.
504
A TEXT-BOOK OF GYNECOLOGY.
Dulcamara.-Painful pressing down in the region of the
bladder and urethra; especially useful in chronic cases with con-
stant desire deep in the abdomen to urinate, particularly if
brought on or perpetuated by exposure to local damp or cold; urine
is very offensive and is loaded with mucus.
Pulsatilla.—Tenesmus and stinging in the neck of the blad-
der, the pain continuing after micturition; gonorrheal urethritis
with thick yellow, or yellowish-green discharge; INFLAMED eyes;
scanty urine with restlessness; suppressed gonorrhea.*
Equisetum hy.-Urine high colored and scanty; dysuria
with severe pain, especially just after voiding urine; pain and
tenderness in region of bladder with feeling of distention. †
Mercurius cor.-Fever with chilliness; violent urging; urine
flows in a thin stream, or only drop by drop, containing mucus
and pus; during micturition sweat breaks forth; SYPHILITIC URE-
THRITIS; in children who perspire profusely, whose urine is hot
and acrid, with sudden irresistible desire to urinate.
Uva ursi.-Frequent urging with slight discharge and burn-
ing, cutting pain afterward; the urine is yellow and deposits a
tough mucus.
Copaiva. Urethritis with burning at the neck of the bladder
and in the urethra; the discharge is of a milky color and of a
corrosive character.
Cubeba.—Cutting and constriction after micturition; the dis-
charge is of a mucous character.‡
*"In cystitis and catarrh of the bladder we find Pulsatilla indicated when there
is frequent urging to urinate with pressure on the bladder as if it were too
full. There is pain in the urethra. The urine itself is often turbid from the admix-
ture of mucus. Clinically we have not found pulsatilla a first-class remedy in cysti-
tis, but we have found it almost always the remedy in cystic symptoms accompanying
pregnancy. It yields to cantharis, equisetum, and dulcamara in cystitis.”—Farring-
ton.
+"Equisetum acts very similarly to cantharis on the kidneys and bladder. There
is, however, less escape of blood and less tenesmus vesicæ than may be found under
cantharis. The urine is less scalding and does not contain so many fibrinous flakes.
Cantharis is not called for so often as equisetum when there is an excess of mucus in
the urine.”—Farrington.
"Both Copaiva and Cubeba are useful in the irritation attending thickening of the
lining membrane of the bladder. Neither remedy has as violent an action as has
cantharis.”—Farrington.
DISEASES OF THE URETHRA AND BLadder.
505
Petroselinum.-Sudden urging to urinate; gonorrhea with
sudden urging and strangury. "In the case of a child it will be
suddenly seized with a desire to urinate. If it cannot be grati-
fied immediately it will jump up and down with pain.”—Far-
rington.
Ferrum phos.-Cystitis with dysuria, which is brought on
by standing.
Berberis vulg.-Cystitis associated with cutting lesions;
sharp, stitching pains, radiating from the region of the bladder in
all directions, particularly downward and forward, filling the
whole pelvis with pain.
Cannabis sat.-Sudden urging with difficult urination; cut-
ting pains during micturition between the labia, with violent
sexual desire; swelling of the vagina; the orifice of the urethra
is closed with muco-pus.
Belladonna.-The region of the bladder is sensitive to touch;
urine hot and red; shooting pains; cerebral excitement.
Arsenicum.—Burning pain, especially at commencement of
urination; chronic cystitis with inability to void the water;
symptoms of sepsis; urine turbid and mixed with mucus and
pus.
Lycopodium.-Chronic cystitis with fever; disposition to urin-
ary concretions; URIC ACID DIATHESIS.
Terebinthina.—Sensitiveness of hypogastrium; tenesmus of
bladder with strangury and pain in urethra; urine retained from
atrophy of fundus vesicæ; catarrh of the bladder in old persons
of sedentary habits.
Camphora. Especially useful after abuse of cantharis and
terebinthina; complete suppression of urine; slow and thin
stream; burning in urethra and bladder;
Consult:-Elaterium, eupatorium purp., helleborus, populus,
sepia, hyoscyamus, lachesis, sulphur, and tarantula.
CHAPTER XXXIII.
DISEASES OF THE URETHRA AND BLADDER
(Continued).
MALFORMATIONS OF THE Urethra.
Congenital malformation of the urethra is usually associated
with more or less malformation of the sexual organs and requires
no extended description. The canal may, however, be entirely
absent when the genital organs are normal, or it may be imper-
fectly developed at its lower portion only (hypospadiasis). A
more common congenital defect is complete atresia. A case is
recorded by Skene in which delivery was impeded by the dis-
tended fetal bladder, caused by atresia. The treatment of these
various abnormalities is purely surgical.
STRICTURE OF THE URethra.
As in the male, though much less frequently, gonorrhea and
non-specific inflammation may result in stricture of the urethra,
and even in complete atresia. Stricture more or less marked is also
met with in long-standing vesico-vaginal fistula sufficiently large
to permit all of the urine to pass through it. The contraction
may involve the entire length of the canal or only a portion of it,
being oftener confined to the meatus. In difficult or painful mic-
turition the possibility of stricture should always be borne in
mind and the caliber of the canal measured. This is done by
means of a sound, carefully inserted. The normal female ure-
thra should admit with perfect ease a number twelve male sound
(English scale). Distortion of the canal without stricture some-
times interferes with its introduction.
·
The same principles observed in the treatment of stricture in
the male urethra are applicable to stricture in the female. Gra-
dual dilatation is preferable to rapid if it will accomplish the
desired end, as it usually will. This can be done by the repeated
introduction of graduated sounds, cocain being first used if the
506
PROLAPSE OF URETHRAL TISSUES.
507
pain is great. If this fail, rapid dilatation under ether may be
made, using for the purpose an ordinary smooth steel uterine
dilator or Pratt's urethral speculum. The graduated sounds
should be passed at frequent intervals after this operation.
PROLAPSE OF THE MUCOUS AND SUBMUCOUS TISSUES OF THE
URETHRA.
The most frequent cause of this accident is parturition. The
mucous membrane and submucous tissues become, according to
Emmet, split or lacerated in the long axis of the canal as the
urethra is squeezed between the arch of the pubes and the fetal
head. The peculiar loose structure of the tissues causes them to
be rolled out from the urethra in advance of the child's head, the
mechanism being not unlike that which forces the rectal mucous
membrane from the anus.
The slight degree of prolapse in many of these cases is indi-
cated only by the deeper red color of the urethral surface pre-
senting itself at the outlet, for the retraction resulting from cica-
trization prevents a more serious displacement. Troublesome
symptoms do not always immediately follow the injury, and the
patient may not be conscious of the accident for some weeks or
months afterward, when the unnatural sensations are often attri-
buted to some displacement or lesion of the uterus. Usually,
however, the trouble can be traced back to some particular labor,
after which pain and uneasiness at the neck of the bladder were
experienced for the first time. A subsequent examination will
reveal prolapse at the outlet of the urethra, occupying, as the
case may be, either the entire circumference of the canal, or only
the lower or upper portion of its orifice.
Fig. 81 represents an exaggerated instance of urethral pro-
lapse, which came under my observation during the fall of 1886.
The case is the one referred to on page 207.
The con-
dition shown had existed for eighteen years, giving rise to a
most distressing reflex asthma, which was entirely cured by re-
moving the prolapsed tissue. The tumor was as large as a hen's
egg. A careful physical examination, followed by the introduc-
tion of the sound or catheter, is usually sufficient to distinguish
the accident from caruncula, polypus, and venous angioma.
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A TEXT-BOOK OF GYNECOLOGY.
Treatment. If the prolapse is at all marked, surgical interfer-
ence is usually necessary. It may be aggravated by existing pelvic
cellulitis or anal fissures, in which event treatment should also be
directed to these affections. The tissue was removed in the fore-
going case by making a superficial incision around the base of
the tumor, transfixing it with a double ligature, tying on
either side, as in dealing with hemorrhoids, and cutting the mass
away. Seguin first introduces a female catheter into the bladder,
and then strangulates the tumor with a ligature thrown
around its base. The catheter is not withdrawn until the base of
FIG. 81.

A
B
A. TUMOR. B. CATHETER INTRODUCED INTO URETHRAL ORIFICE, C. (Wood.)
the tumor is entirely severed. It may also be removed by the
galvano-cautery wire, as suggested by Thomas.
Emmet condemns the removal of the mass in the circular
variety of urethral prolapse. He says that many times only tem-
porary relief follows the operation, while a serious and perman-
ent stricture often results. He first reduces the hypertrophied
tissues by making an artificial vesico-vaginal fistula, thus divert-
ing the flow of urine from its natural outlet. Then, by the aid of
a steel or block-tin sound, he carefully returns from time to time
DILATATION OF THE URETHRA.
509
the prolapsed tissues, which are made to contract by the applica-
tion of strong tincture of iodin introduced through a conical ear
speculum, or some similar instrument. After the urethra is res-
tored as near to its normal condition as is possible by this treat-
ment, he performs an operation for the cure of the prolapse in this
way: A button-hole incision is made in the urethra through which
the excess of tissue is drawn back from the meatus, secured in its
edges, and cut off, after which the opening is closed. This oper-
ation is an ingenious one and, when the prolapsed tissues are not
too much hypertrophied, is undoubtedly more satisfactory than
is the one done by myself. The hypertrophy, however, in the
case given, was such as to make Emmet's operation imprac-
ticable.
DILATATION OF THE URETHRA.
This may result from growths within the canal, from stricture
at or near the meatus, from the introduction of foreign bodies, or
from the passage of calculi. In atresia of the vagina, the
urethra may be sufficiently dilated to receive the male organ
during intercourse. Thorburn cites a case of atresia vaginæ
in which the urethral dilatation was so great that injections
were given through it into the bladder, the urethra simulating
the vagina. Oftentimes there is chronic inflammatory thick-
ening of the mucous membrane.
Symptoms.-Disturbed micturition will attract attention to
the urinary organs. Upon physical examination there will be
found either a tumor of some kind which has given rise to ob-
struction of the urethra at its lower orifice, or inflammatory
hypertrophy of its mucous membrane. A sound introduced
beyond the point of obstruction will reveal the increased caliber
of the canal. Urethritis is often associated with the condition,
the discharge being purulent or muco-purulent in character.
Treatment. If the dilatation is not great it may be treated
by astringents, hot douches, etc. Any obstruction at or near
the meatus should be removed. In the event of cystocele or
relaxation of the pelvic floor these conditions should be cor-
rected. If the dilatation is not overcome by these several
methods, Emmet's button-hole operation will afford relief from
Uor M
510
A TEXT-BOOK OF GYNECOLOGY.
the distressing symptoms. The opening is made at the most
dependent part of the urethra, either with a sound or scalpel, or
with button-hole scissors especially constructed for the purpose.
The mucous membrane of the urethra is then stitched to that
of the vagina by a running catgut suture, as in colpocystotomy.
If the urethral mucous membrane is very redundant, a portion
of it may be excised. This opening affords free drainage and
greatly facilitates irrigation, as well as the application of medica-
ments. Or, Skene's operation for prolapse of the urethra may
be resorted to. This consists of an incision half-an-inch long
on either side of the urethra, extending from the vulva upward
and outward. With a continuous catgut suture the tissues are
attached to the fascia of the sub-pubic ligament. The first row
of sutures is buried while the edges of the wound are retracted;
the second unites the divided mucous membrane. The tissues
are thus gathered together on each side of the urethra and the
prolapse is overcome.
FISSURE OF THE Urethra.
The mucous membrane of the urethra, like that of the rectum,
is sometimes rent in such a way as to create a fissure. In the
urethra it is usually located at its vesical extremity. It may give
rise to very distressing dysuria, with tenesmus and spasmodic
contractions of the bladder.
The diagnosis will have to be made by exclusion-there
being an absence, on physical exploration, of those lesions
attended with similar symptoms. An expert with the endoscope
may be able to see the fissure, but this is extremely difficult
when the lesion is located high up in the canal.
The treatment consists of both internal and local medication.
Magnesium phos., cantharis, mercurius cor., and cannabis sativa
will be the remedies oftener indicated. I have succeeded in
curing several cases by protecting the fissure with oleaginous
collodion, as recommended by Ludlam. The solution is brought
in contact with the parts by means of an ordinary straight medi-
cine dropper, the tip being inserted as far as the neck of the
bladder. Suppositories composed of iodoform, bismuth, or
belladonna sometimes do much good.
Maou
VASCULAR NEOPLASMS: URETHRAL CARUNCLES.
511
As a last resort dilatation may be made and it usually accom-
plishes a cure. I have, in another place, cautioned against too
great dilatation of the urethra because of the danger of inconti-
nence. The rule laid down by Skene, and it is a good one, is
this: Ascertain how large a sound can be passed with ease and
then dilate sufficiently to admit another three or four sizes larger.
If this rule is carefully observed there will be but little danger
of creating incontinence.
Finally, if forcible dilatation fail to produce sufficient physi-
ological rest to cure the disease, an opening may be made into
the bladder through the vagina. This will keep the urine from
coming in contact with the fissure, and by the time the artificial
opening closes spontaneously, the lesion probably will have
healed.
VASCULAR NEOPLASMS OF THE URETHRA.
An increase in the caliber of the venous radicals will give
rise to over-distention and the formation of tumors, which are
known as angiomæ, varices, or phlebectases. They are analo-
gous to rectal hemorrhoids and may occupy any portion of the
urethra, though the vessels of the urethro-vaginal septum are
the ones oftener implicated. These growths, unlike urethral
caruncles, are not painful.
The treatment is the same as that recommended for urethral
caruncles.
URETHRAL CARUNCLES.
Skene describes these formations under the head of Compound
Neoplasms. They are, technically, papillary polypoid angiomas,
and vary in size from a millet-seed to a hazelnut. They are of
a crimson or deep red color, soft, friable, more or less peduncu-
lated, and exquisitely painful to touch and upon passing urine.
They spring from the urethral wall near the meatus. Occasion-
ally they are concealed entirely within the urethra, or they
may completely encircle the meatus, resembling the minor
degrees of prolapse of the urethral mucous membrane.
Histologically, these growths are made up of fine loops of
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A TEXT-BOOK OF GYNECOLOGY.
capillaries, with a limited amount of connective tissue and a
varying supply of nerves.
Symptoms.-Pain upon micturition, sometimes very great,
is usually the chief symptom for which the patient seeks relief.
Dyspareunia and vaginismus may be most distressing. If
large enough to interfere mechanically with urination, the
act is not only painful, but difficult as well.
These growths can be differentiated from angioma by their
greater sensitiveness, their brighter color, and their tendency to
bleed. They do not shrink under pressure, as do the vascular
neoplasms.
Treatment.-This consists in total ablation of the morbid
growths, either by means of scissors, the actual cautery, or
caustics. My method of operating is as follows: The patient
is placed in the lithotomy posture and the parts exposed; a
twenty per cent. solution of cocain is then applied to the growth
or growths by means of absorbent cotton. The tumor is
next seized with a pair of tissue forceps and put upon the
stretch. It is then removed close to the healthy structures
by means of the Pacquelin, or the galvano-cautery knife. By this
method the extent of tissue destroyed is entirely under the
control of the operator, which is not the case if caustics are used.
Should the tumor or tumors be located higher up in the
urethra, à speculum will be necessary in order to expose them.
Skene recommends Allen's ear polypus forceps for grasping the
tumor under these circumstances. When still higher up in the
canal it may be necessary to use the snare, for which purpose
Blake's polypus snare will be found useful.
POLYPI OF THE URETHRA.
Occasionally polypi spring from the urethra. Urethral
caruncles may take on a polypoidal form; these have already
been considered. Small pedunculated fibromata may also
be located in or about this canal. And, most rare of all
forms, are occluded glandules, which assume a polypoidal shape.
The treatment is, in all instances, surgical and does not differ
from that given for urethral caruncles.
IRRITABLE URETHRA: VESICAL CALCULI.
513
IRRITABLE URETHRA.
The mucous membrane of the urethra, like the mucous mem-
brane of other parts of the body, sometimes becomes irritable
or hyperesthetic without any local disease to account for such
irritability. The condition is not unlike that of the so-called
hysterical rectum so graphically described by Weir Mitchell. It
gives rise to frequent micturition, especially after undue exercise
or nervous excitement; and pain during sexual intercourse. The
most careful examination will fail to reveal local evidences of
disease.
The treatment is dilatation according to the same method
recommended for fissure of the urethra. The operation may
have to be repeated several times, but in the end will, in nearly
all instances, accomplish a cure. Of course proper measures,
having for their object the correction of any constitutional bias
that may exist, should be observed. Galvanism is also
beneficial.
VESICAL CALCULI.
Stone in the bladder does not occur in women nearly so often
as in men. When it does occur the causes are much the same
as in the male, the uric acid diathesis being responsible for it
oftener than anything else. Foreign bodies are more apt to find
their way into the bladder in women than in men, being usually
introduced for purposes of masturbation. Thus, through the
urethra, hair-pins, matches, and even spools, have been introduced
for this purpose, around which incrustations may form.
In all cases of chronic cystitis the bladder should be sounded
for stone. When a metallic instrument comes in contact with
it the sensation elicited is sufficiently characteristic to make the
diagnosis certain. Sometimes the calculus is so large that it
can be detected on bimanual examination.
The treatment is essentially surgical, and measures should be
taken to remove the foreign body as soon as it is detected. If
the stone is small, an attempt may be made to crush it through
the urethra by forceps or the lithotrite, after which the detri-
tus can be washed away. However, a large stone should not be
33
514
A TEXT-BOOK OF GYNECOLOGY.
removed in this way. The bladder is so easily gotten at
through the vagina as to make it unwise to jeopardize the ure-
thra by over-stretching. Indeed, in nearly all instances of
vesical calculus there is a cystitis which is best cured by colpo-
cystotomy. In a case operated upon by me for Dr. L. E. Gal-
lup of Marshall, I removed, per vaginam, a stone weighing
nearly 600 grains, the only anesthetic used being cocain.
Notwithstanding the large opening required, no effort was
made to close it and it healed spontaneously in less than
three weeks' time, the drainage afforded curing the cystitis.
NEOPLASMS Of the BladdER.*
The various neoplasms occurring in other parts of the body
may have their origin in the bladder. The villous variety of
cancer is the one most frequently found in this locality. It
usually runs a rapid course, yet sometimes the duration of the
disease will extend over a period of several years. Cancer gives
rise to a good deal of pain and the urine is often tinged with
blood. A diagnosis can be made by the use of the cysto-
scope, but ordinarily it is necessary to explore the bladder either
through the urethra or through the vesico-vaginal septum.
The prognosis is unfavorable, though life may be prolonged for an
almost indefinite period by removing the growth as thoroughly
as possible with a sharp curette, the hemorrhage being controlled
by hot irrigation. Care must be observed not to injure the ure-
ters in the efforts made to remove the disease.
The other neoplasms found in the bladder are pathological
curiosities. Cysts containing hair, teeth, sebaceous matter, etc.,
sometimes, though rarely, exist as indigenous tumors. In the
vast majority of instances, these substances, when found within the
bladder, are of outside origin. Polypi of varying structure-true
fibromata, fibroid hypertrophy of the mucous membrane, tubercu-
lar growths, etc., are likewise occasionally found within the
bladder. It is exceeding difficult to differentiate these various
growths from malignant disease, unless a portion can be removed.
and subjected to microscopic examination. In all instances
* The reader is referred to the excellent monograph on "Tumors of the Bladder,"
by Sir Henry Thompson, F. R. C. s., London, 1884.
IRRITABILITY OF THE BLADDER.
515
an attempt should be made, either through the urethra or through
an artificial vesico-vaginal fistula, to remove them.
VESICAL PARASITES.
In this climate these are almost unknown. They usually
reach the bladder either through the urethra, through fistulæ,
or by passing downward from the kidneys through the ureters.
Vesical parasites are very much more frequent in tropical or
sub-tropical regions. True hydatids are occasionally met with
in the bladder, as in all other parts of the body. The symp-
toms are those of vesical irritation, with occasional attacks of
hematuria. If the parasites pass from the kidneys through
the ureters the patient will suffer during their transit from all
the symptoms of nephritic colic. An effort should be made
to remove them through the urethra.
HEMATURIA.
So-called hematuria is a symptom of several of the condi-
tions which have already been studied. It may be due to pur-
pura or hemophilia, to simple local congestion, to fungosities
of various kinds, to kidney lesions, to calculi, to foreign bodies,
or to zymotic and malarial diseases. It is always important to
determine the source of the blood when it appears in the urine.
If there are clots large enough to be visible to the unaided eye,
the source of the hemorrhage must be below the secreting
structures. If the bladder is the source, the clots are often
large and may lodge in the urethra, causing retention of the
urine. If the coagulation takes place within the ureters, this
will be indicated by the shape and size of the clots; if from the
substance of the kidney, the clots, having been formed in the
tubules, will be of microscopic size, and the urine will usually
have a smoky tint. (Vaughan.)
IRRITABILITY OF THE BLADDER.
The same factors inducing irritability of the urethra may also
give rise to irritability of the bladder.
hysterical and very nervous patients.
It occurs oftener in
There are, however,
other causes, which give rise to frequent micturition by inducing
516
A TEXT-BOOK OF GYNECOLOGY.
irritability of the bladder. Of these anteversion and ante-
flexion are the most frequent. Irritability of the bladder is
also a common symptom of early pregnancy, and is due both to
the increased weight of the uterus, the fundus resting upon the
bladder, and to the exaggerated pelvic congestion. Indeed,
any condition increasing the blood supply of the pelvis may
cause irritability of the bladder. It is not infrequently associated
with dysmenorrhea, tumors of the uterus and of the ovaries,
pelvic inflammation, and periuterine hematocele. In all
instances of irritability, however, the urethra should be carefully
explored for excrescences and inflammation, and the urine
examined for evidences of organic disease of the urinary organs.
The cause of the irritability will sometimes be found in the
urine itself, as when it is excessively acid or contaminated with
pus or blood.
Fine oxalates are often present in the urine of
nervous and gouty subjects, and give rise to much irritation.
They may be detected with a fairly good microscope.
RETENTION of Urine.
This may result from purely nervous causes, or it may be due
to organic disease of the bladder. In
In nervous cases the
urine is sometimes retained for several days, and there may be
almost absolute suppression, which condition is known as
hysterical ischuria. The retention is often voluntary in cases of
irritable carunculæ and other diseases of the urethra, the
patient dreading the pain resulting from micturition. Retention
frequently occurs, too, after operations upon the rectum, it being
often necessary to use the catheter for several days following
divulsion of this organ.
As in the male, it is a frequent symptom in paraplegia, and
the bladder should always be watched in cases of paralysis of
the lower half of the body. Temporary paralysis of the bladder
may also result from over-distention of this organ; after a
certain degree of distention is reached, the urine cannot be ex-
pelled. This condition frequently prevails in puerperal cases,
and the distention may be so great as to produce a dribbling of
urine without creating the slightest desire to evacuate the blad-
der.
RETENTION OF URINE.
517
It may likewise be due to any of the various lesions or dis-
eases which give rise to pressure upon the neck of the bladder
or upon the urethra, the retention being purely mechanical.
Impacted fibroid or ovarian tumors, pelvic abscess, retro-uterine
hematocle, incarcerated retroversion or retroflexion of a gravid
uterus-any or all of these several conditions exert pressure and
tend to obstruct the flow of urine.
I have elsewhere cited a case (p. 62) in which the distention was
so great as to give rise to suspicions of pregnancy. In all instances
in which the patient has not urinated for some time, or in which
there is a dribbling of urine, the bladder should be carefully
examined for retention. It will be indicated by dulness in the
hypogastric region, by bearing down intermittent pains, and by
a sensation of distention in the lower abdomen. Care should
always be taken to differentiate retention from suppression of
the urine. In all cases of doubt the catheter will clear up the
diagnosis. After the retention is temporarily relieved by the
introduction of the catheter (in excessive distention the bladder
must not be too suddenly emptied), measures should be taken
to remove its cause, whatever it may be. In cases of temporary
paralysis the catheter may have to be used for several days.
Local faradization will here do much good. Belladonna, nux,
gelsemium, camphora, and opium are to be thought of as inter-
nal remedies. If due to paraplegia, the vesical paralysis is likely
to remain as a permanent condition.
CHAPTER XXXIV.
FISTULÆ OF THE FEMALE GENITAL ORGANS.
VESICAL AND URETHRAL FISTULÆ.
The varieties of vesical and urethral fistulæ are:
Vesico-vaginal;
Urethro-vaginal;
Uretero-vaginal;
Vesico-uterine;
Uretero-uterine.
The location of the several fistulæ enumerated is clearly indi-
cated by the names given. Of these vesico-vaginal fistula is by
all odds the most frequent. The urethro-vaginal is rarely met
with except when the opening is artificially made. The uretero-
vaginal and uretero-uterine are still more rare accidents and,
when they occur, usually result from some operative procedure
within the pelvis.
Pathology. The extent of tissue lost varies greatly. There
may be but a small opening, barely admitting a fine probe, con-
necting the vagina and bladder; or the whole base of the bladder
may be destroyed, together with the urethra. All forms of
fistulæ tend to become smaller from secondary contraction as
time goes on.
At first the margins are thick, irregular, and, frequently, ulcer-
ated; later on, however, cicatricial contraction causes them to
become thin and firm.
As time progresses, contraction and thickening of the bladder
walls take place; and, if the opening between the bladder and
the vagina is very large, the vesical mucous membrane may
protrude through it. In extensive fistulæ the destruction of tissue.
may involve the openings of the ureters. The urethra, from
want of use, also becomes contracted, and, indeed, atresia of this
organ may occur. Often, too, there is associated with the acci-
dent injury to the vagina with resulting cicatricial contraction.
518
URINARY FISTULÆ.
519
This may so distort the canal as to make it difficult to ascertain
the size and location of the fistula.
It is exceedingly difficult to locate vesico-uterine fistulæ, and in
order to do so it is necessary to dilate the cervical canal. These
fistulæ are usually small.
Uretero-vaginal fistulæ are located in one of the fornices of
the vagina.. They, too, are very small, admitting the point of a
fine probe only.
Uretero-uterine fistula so rarely occur as to constitute, when
they do, pathological curiosities.
Etiology. The causes of fistulæ may be enumerated as
follows:-
Injuries received during labor;
Traumatism;
Ulceration and abscess.
Of these, the injuries and accidents incident to childbirth
are of first importance. Long continued pressure of the fetal
head is a most prolific cause. It may, however, follow rapid
labor, the tissues being unduly bruised by compression between
the fetal head and the bony pelvis. In either event death of
tissue ensues from the unnatural pressure, and subsequent
sloughing gives rise to fistula.
use.
Unquestionably, fistulæ may be produced by the unskilful ap-
plication of instruments. However, in by far the larger number
of cases the accident results, not from the intelligent application
of the obstetric forceps, but rather from too long deferring its
After the head has been wedged in the pelvis for a long
time the mischief is already done; and, while there is danger of
immediate laceration attending the use of the instruments, the
primary cause of such laceration is, in neglected cases, the
long-continued pressure which has made the tissues fragile.
I especially emphasize this point because too often the attending
physician, with whom the responsibility entirely rests, holds the
consultant responsible for an accident which might have been
avoided had the forceps been applied earlier.
In the various other obstetric operations, especially those in-
volving the destruction of the fetus, there is danger, if the instru-
ments are carelessly used, of lacerating the vaginal walls. When
520
A TEXT-BOOK OF GYNECOLOGY.
craniotomy is performed care should be taken that the sharp
edges of the cranial bones do not produce such injury, or that
the crotchet and blunt hook do not slip during traction and in-
jure the vagina.
Of the traumatic causes, the most frequent is a fall upon
some sharp object. This occurs oftener in children and
young girls than in adults. The careless manipulation of instru-
- ments within the vagina in the various operative procedures
through this canal may give rise to fistulæ. I unwittingly
penetrated the bladder in one case of vaginal hysterectomy.
Symptoms.-The first symptom suggesting the presence of the
accident is incontinence of urine. This may be partial or absolute,
depending upon the size of the fistula. If the opening is very
small, part of the urine may be passed through the urethra. In
almost all instances, however, in any of the forms of vesical
fistula, the entire quantity of urine passes through the unnatural
opening. This is frequently the only symptom, though in those
cases where there is sloughing of tissue or ulceration, the local
pain and distress are sometimes very great; or, if inflammation
attends the accident, the usual symptoms of cystitis and
urethritis manifest themselves.
When the accident follows parturition, there is usually more
or less paralysis of the bladder for several days preceding the
formation of the fistula, during which time the frequent use of
the catheter is necessary. After the separation of the slough
the urine escapes through the vagina. This may remain as a
permanent condition; or, if the opening is not large, subsequent
cicatrization may result in its closure, when the urine will again
be passed through the natural channel.
The secondary symptoms of urinary fistulæ are due to con-
tact of the urine with the vagina, external genital organs
and neighboring surfaces. The labia, the perineum, and the
inner surface of the thighs become red, inflamed and even
ulcerated. It is exceedingly difficult for the patient to keep
herself free from the urinous odor arising from this condition.
Often, too, urinary deposits, consisting of urates and phosphates,
form in crusts about the edges of the fistula and within the
vagina, giving rise to great irritation.
URINARY FISTULÆ.
521
The foregoing symptoms will clearly indicate that some un-
natural condition of the urinary organs exists; but in order accu-
rately to locate the fistula a physical examination is necessary.
Physical Signs.-If an exploratory examination is made
soon after delivery, great gentleness should be practised. In
the event of a large opening between the vagina and the bladder,
the finger will readily pass into the latter organ, and the
diagnosis is easily made. Greater difficulty will be experienced
if the opening is very small; in that case its exact location is
sometimes hard to determine.
In the event of doubt, proceed as follows: Place the patient
in the Sims posture, before a good light. Introduce into the
bladder through the urethra a catheter, to which is attached a
rubber tube and funnel such as is used for washing out the
bladder in cystitis. Through this distend the bladder with
some colored fluid-milk or a weak solution of permanganate
of potash. If the fluid escapes through the fistula, the
location of the latter will be determined. In the event of
vesico-uterine fistula the fluid will escape through the external
OS. If the opening cannot be located by this method, the
colored fluid failing to make its appearance after being forced
into the bladder, either through the vagina or through the
cervical canal, it is reasonably certain that there is no connection
between the bladder and the vagina, or between the bladder and
the uterus. This test is not absolute, for there may be a valve-
like condition of the vesical mucous membrane, which will
prevent the escape of the fluid from that viscus. Should
such an opening not be found, the fornices of the vagina
should be carefully explored for a ureteral fistula. Repeated
examination may be necessary before a small fistula is finally
located.
It is sometimes possible, in vesico-uterine fistula, to pass the
sound from the bladder into the cervical canal, at which point it
is detected by passing a second sound through the external os.
Prognosis. Simple fistulæ resulting from childbirth are
many times spontaneously cured. After the opening once be-
comes permanent, however, a spontaneous cure never results.
The curability by operative procedures will depend upon the size
522
A TEXT-BOOK OF GYNECOLOGY.
of the opening, its location, its cause, and the complications due
to changes within the vagina. Fistulæ involving the base of the
bladder are more easily gotten at and are, consequently, more
amenable to treatment. On the other hand, vesico-cervical fis-
tulæ and ureteral fistulæ, particularly the latter, present special
difficulties. In dealing with the ureter, it is very difficult to
prevent permanent stricture of the canal.
Treatment.-Whenever a urinary fistula is suspected the
catheter should be introduced at once in order to make sure that
the discharge does not come from the urethra because of over-
distention of the bladder. If it is evident that the urine escapes
through the vagina, the patient should be placed in a favorable
posture for examination, and the opening carefully looked for.
If it is small, the urine should be drawn every three or four hours,
or else a self-retaining catheter kept constantly within the blad-
der. For this purpose I know of nothing better than the glass
instrument of Kustner held in situ by strips of adhesive plaster.
I much prefer it for this purpose to the Skene-Goodman cathe-
ter recommended by most writers. (Fig. 82.)
FIG. 82.
G.TIEMANN-CO.
SKENE'S MODIFICATION OF GOOD-
MAN'S SELF-RETAINING CATHETER.
It is necessary to keep the
patient upon her back in order to
prevent the lochial discharge from
passing into the bladder. The
vagina should be kept absolutely
clean by the frequent use of a 1:
4000 bichlorid douche. In every
respect the most scrupulous cleanliness should be practised.
By observing these precautions a cure will result in a goodly
per cent. of cases. This is especially true if the fistula attends
any of the operations within or through the vagina. In the case
referred to, in which it followed vaginal hysterectomy, the open-
ing was large enough to permit the introduction of the finger,
yet it healed perfectly in less than two weeks' time.
It is not wise to undertake to close the fistula too soon after
parturition-not earlier than three months. The best results.
cannot be obtained until after the patient has passed through
the puerperal changes. It is always wise, under any circumstances,
to get the system into the best possible shape before undertaking

URINARY FISTULÆ.
523
to close the opening, bearing in mind, of course, the fact that
the existence of the fistula may be responsible for the continued
ill-health.
OPERATION FOR VESICO-VAGINAL FISTULA.
A certain amount of preparatory treatment is usually neces-
sary in order to obtain the best results. If there is local inflam-
mation, this should be treated by frequent douchings and suitable
medication. If the irritation about the external genital organs
is great, Lyster's ointment of boracic acid, or some of the ap-
plications recommended for pruritus vulvæ, will add greatly to
the patient's comfort by relieving the excoriation. All incrusta-
tions which form on the edges of the fistula and within the
vagina should be removed with forceps at least every two or
three days. If there are any evidences of cystitis, this should
be dealt with by washing the bladder through the urethra. If
the fistula is of long duration, it may be necessary gradually to
dilate the urethra in order to insure its patulency when the flow
is directed through it. This can be done according to the
method described in dealing with stricture of the urethra (page
506). Should there be stricture of the vagina, or cicatricial
bands which exert traction upon the bladder, these must be
overcome before an effort is made to close the opening. The
cicatricial bands should be divided and the canal kept dilated for
a suitable length of time. Should it be impossible to remove
entirely the scar-tissue, much good can be done by constant dis-
tention with vaginal tampons, used for some weeks previously to
the operation.
The patient should be placed in the Sims posture before a
good light. It is best to administer an anesthetic, not because
of the excessive pain attending the operation, but because of
the importance of perfect quiet on the part of the patient.
Sims' speculum is a sine qua non. The operator cannot very
well get along with less than four assistants-one to hold the
speculum and elevate the nates, a second to care for the irrigator
and do the sponging, a third to look after the instruments, and
a fourth to administer the anesthetic. If but three assistants
are available, the operator can himself manage the instruments
524
A TEXT-BOOK OF GYNECOLOGY.
by having the tray near at hand. It is best to have a variety of
needles of various curves and lengths with silk leaders secured
in the eyes. The instrument tray should contain: Long-hand-
led, curved scissors; at least two tenacula; wire twister; long-
handled knife with narrow blade; needles and needle holder;
counter-pressure hook; Sims' speculum and fork; and silver
wire Nos. 29 and 30. In addition there should be from four to
six sponge holders containing sponges of suitable size.
The steps of the operation are three :-
1. Vivifying the edges of the fistula;
2. The introduction of sutures;
3. Coaptating the edges of the fistula and securing the sutures.
FIG. 83.

G.TIEMANN-CO.
SIMS' CURVED SCISSORS.
FIG. 84.
80

G.TIEMANN-CO
BOZEMAN'S STRAIGHT SCALPEL.
Vivifying the Edges of the Fistula.-The lower edge of
the fistula should be first vivified. This is done by picking up
the tissues, either with a tenaculum or tissue forceps, as the
operator may prefer. I use almost entirely in plastic work tena-
cula instead of tissue forceps. Then with a pair of curved scissors
(Fig. 83) or with a long-handled narrow scalpel (Fig. 84) a strip of
tissue is removed three-eighths of an inch in width, extending
down to the mucous membrane of the bladder. Personally I pre-
fer the scissors for this purpose. Care should be taken not to in-
jure the vesical mucous membrane, because it is very vascular and,
if injured, hemorrhage into the bladder is liable to occur. A strip
of tissue of suitable width can ordinarily be removed in an
unbroken piece. After the lower edge of the wound is vivified

URINARY FISTULE.
525
the upper edge is dealt with in the same way. The denudation
should extend sufficiently beyond the angles of the fistula to
insure against puckering when the edges are coaptated. The
parts should now be carefully inspected in order to ascertain
whether or not any point has been left unvivified. If so, this is
to be picked up with a tenaculum and snipped off. An unvivi-
fied island of tissue might spoil the whole operation.
FIG. 85.
The direction of the long
diameter of the fistula will
determine the line of coap-
tation. When it can be
done this should corres-
pond to the long diameter
of the vagina. Should,
however, the long diam-
eter of the fistula run
transversely, the line of
FIG. 86.
METHOD OF PARING WITH KNIFE.
(Savage.)
METHOD OF PARING WITH
SCISSORS. (Savage.)
coaptation will have to correspond to the transverse diameter
of the vagina.
The hemorrhage is usually not great and can ordinarily be
controlled by hot irrigation. Should there be troublesome
bleeding from an injured artery, it can be controlled by passing
around it a fine catgut suture and tying this upon the vaginal
surface. It is not a good plan, if it can be avoided, to leave
even a fine catgut suture between the vivified edges of a fistula.
526
A TEXT-BOOK OF GYNECOLOGY.
The Introduction of Sutures.-I think that on the whole
silver wire will be found the preferable suture, although some
operators, notably Skene and Simon, have obtained most excel-
lent results with the use of silk. The wire is easily introduced,
FIG. 87.
G.TIEMANN
EMMET'S NEEDLES.
FIG. 88.

SIMS' NEEDLE FORCEPS, WIth Needle.
the degree of tension can be controlled perfectly, and it is not
readily contaminated. A needle of suitable size and length is
a
ს
FIG. 89.
a
C
grasped with the needle holder
at a proper angle. The mucous
membrane of the upper edge of
the wound is held with a tenac-
ulum and the first suture is intro-
duced at the angle farthest from
the operator. The method of pass-
ing the suture is shown in Fig. 89.
The needle should extend only as
far as the vesical mucous membrane, and not penetrate it. Counter
force is made as the needle is passed either with a counter pres-

INTRODUCTION OF SUTURes.
a. Vesical margin. b. Vaginal mar-
gin. c. Point of entrance of needle.
d. Point of exit of needle.
FIG. 90.

G.TIEMANN & CO
EMMET'S COUNTER-PRESSURE HOOK.
sure hook (Fig. 90) or with a strong tenaculum, so that no
URINARY FISTULÆ.
527
undue tension will be exerted upon the tissues. After the
wire of the first suture is drawn
through, the ends are slightly
twisted and handed to the assist-
ant who holds the speculum.
This suture will now steady the
tissues so that the subsequent
ones are more readily intro-
duced. They should be placed
from two- to three-sixteenths
of an inch apart, and should
extend on the vaginal surface.
FIG. 91.

TIEMANN & CO
SUTURES PASSED.
FIG. 92.
at least one-quarter of an inch from the edge of the wound.
The number of sutures used will, of course, depend upon the
size of the opening. At both
angles of the wound there should
be at least one suture extending
beyond the vivified tissue, so as
to overcome all tension at these
points.
Coaptation of the Edges of
the Fistula.-After the sutures
are all introduced temporary co-
aptation is made by drawing to-
gether the ends of the silver wire,
in order to ascertain whether or
not the edges will be perfectly
approximated. A soft rubber
catheter is now slipped over the
end of the irrigating tube and
passed into the bladder, through
which the bladder is thoroughly
washed and freed from all clots
before the wound is finally closed. It is best to keep a con-
tinuous stream of sterilized water flowing into the bladder
until just before the last two or three sutures are twisted, so
that no blood may be left behind to give rise to subsequent
trouble. The ends of the suture farthest from the operator are

TWISTING THE SUTURE.
528
A TEXT-BOOK OF GYNECOLOGY.
untwisted, after which one or two turns are given it near
the wound in order to coaptate the edges. The suture is now
slipped into Sims' shield (Fig. 93) and the loose ends grasped in
a wire twister (Fig. 95), when sufficient torsion is made to ap-
proximate the edges of the wound. There is always danger of
producing too much tension by excessive torsion; the edges of
the wound should be simply brought together without any
puckering of tissue. If the tension is too great, the suture will
cut its way out and the operation will end in failure. Before the
wire twister is removed the suture is shouldered by bending it
over a tenaculum placed as near as possible to the wound. It is
FIG. 93.

f
SIMS' SHIELD.
FIG. 94.
G.TIEMANN &CO,
GTIEMANN & CO.

THE AUTHOR'S SPONGE HOLDER.
FIG. 95.

FIEMAN
THE AUTHOR'S WIRE TWISTER.
then cut off so that about half an inch of the twisted wire is left
lying flat upon the vaginal surface.
Latterly, instead of securing the wire by twisting, I have been
using perforated shot almost exclusively for the same purpose.
These can be passed over the two ends of the wires and compressed
more quickly than it is possible to secure them by twisting; the
tension of the wound can be quite as nicely regulated, and there is
little danger of the sutures becoming buried in the tissues and
lost. I am using the shotted suture more and more in plastic
work as time goes on. The lead plates, which were formerly
considered necessary when the sutures were secured in this
way, I never apply; they are entirely superfluous.
URINARY FISTULÆ.
529
After the wound is completely closed, the bladder is again
washed through the urethra, all of the water being drawn off.
The washing should continue as long as the water is blood tinged.
Clots left behind might give rise to severe vesical tenesmus or to
obstruction of the urethra. It is, therefore, important to have
the bladder perfectly clean before the patient is removed from the
operating table.
After-treatment.-Most operators advise that a self-retaining
catheter be kept in the bladder for several days after the opera-
tion. This always gives rise to more or less irritation of the
FIG. 96.

ท
6.TIEMANN & CO.
貞
​REMOVAL OF SUTURES.
རངས་་
urethra and bladder and seems to me an unnecessary precaution.
If the catheter is carefully introduced every four hours there is
really no necessity for this precaution, and the results in my hands
have been quite as satisfactory as when the instrument has been
left permanently within the bladder. After five or six days the
patient is permitted to urinate spontaneously if she can do so.
Should there be any cystitis left behind after the operation,
this should be dealt with according to the method given for cys-
titis when resulting from ordinary causes.
It is often beneficial
34

530
A TEXT-BOOK OF GYNECOLOGY.
FIG. 97.
SIMON'S POSITION FOR VESICO-VAGINAL FISTULA. (Simon.)
FIG. 98.
SUTURES TIED. (Simon.)

URINARY FISTULE.
531
to wash the bladder once or twice a day for a week or ten days
following the operation.
The vagina should be kept perfectly clean by douching it once
or twice a day with a 1:3000 bichlorid solution. The diet should
be restricted and the bowels kept open.
FIG. 99.
The sutures are removed in from eight to ten days, although
if the silver wire is used they may be left in for a longer period
without setting up irritation. They are removed by placing the
patient upon her side before a good light and introducing a Sims
speculum. The ends of the twisted wire or the perforated shot
are seized with a pair of forceps and gentle traction exerted.
The point of a pair of wire
scissors is then passed
beneath the suture, with
which it is cut, and the su-
ture withdrawn. If there
should be any doubt as to
the success of the opera-
tion, a test can be made by
carefully injecting fluid in-
to the bladder. It must,
however, be borne in mind
that at the end of eight or
ten days union is not very
strong, and by unreason-
able distention of the blad-
der the edges of the wound
may be forced apart. In
case of failure, either com-
plete or partial, subse-
quent operations will have
to be resorted to.
OPERATIONS FOR VESICO-VAGINAL FISTULA
BY FLAP SPLITTING.
In the foregoing descrip- (a) Fistula; (6) vesical wall; (c) vaginal wall.
tion I have given the tech-
(Walcher.)
nique as practised by most modern operators. It varies some-
what from that practised by Dr. Sims, who first employed the
quill suture but subsequently discarded it for the interrupted.
Bozeman, Baker Brown, Agnew, Simpson, Simon, and many

532
A TEXT-BOOK OF GYNECOLOGY.
others have modified the operation and have special methods of
their own.
Simon's method is particularly unique and original. Its chief
features are:-
1. Substitution of the exaggerated lithotomy position for the
semi-prone.
2. Silk is used for suture material instead of silver wire.
FIG. 100.
3. The mucous mem-
brane of the bladder, es-
pecially if it contains
much cicatricial tissue, is
invaded.
4. The after-treatment
is negative. No perma-
nent catheter is used and
the patient is permitted to
urinate spontaneously as
soon as she is able to do so.
One great advantage of
the lithotomy posture is
the possibility of using
Fritsch's irrigating spec-
ulum, which cannot be
done in the Sims posture.
I found the position ex-
ceedingly useful in an
operation in which it was
necessary to utilize the
anterior lip of the cervix
in order to close a large
fistula which opened high
up in the vaginal fornix.
Modifications of the Technique.-If the operation is un-
usually difficult and the opening large, it may be best to close it
at several sittings. It is also recommended that, when the edges
of the wound are exceedingly vascular, instead of vivifying the
entire surface at once, a small portion only be denuded and
immediately closed with sutures.
OPERATION FOR VESICO-VAGINAL FISTULA BY
FLAP SPLITTING.
Schematic figure of the different stages. (Wal-
cher.)
URINARY FISTULE.
533
The flap-splitting method, now so extensively used in opera-
tions upon the pelvic floor and perineum, has also been applied
to closing various forms of fistulæ opening into the vagina. Those
who especially advocate this method are Tait, Herff, Fritsch,
Walcher, and Sanger. Walcher uses catgut for the purpose of
uniting the vesical lips; he then closes the vaginal wound with
ordinary antiseptic silk. Figs. 99 and 100 show the successive
steps of this operation more clearly than it is possible to describe
them by words.
VESICO-VAGINAL FISTULÆ REQUIRING SPECIAL OPERATIONS.
In case of a triangular fistula the wound, when it is closed, will
be Y-shaped, whereas a quatrilateral opening will have to be
closed by four lines of sutures. Should the fistula be situated
close to the cervix, its anterior lip may have to be utilized in or-
der to close it. This is done by denuding the edges of the
fistula in the usual way and then removing a corresponding strip
of mucous membrane from the anterior portion of the cervix, so
that the edges of the fistula can be attached to the vivified sur-
face of the cervix. In a case of this kind sent to me by Dr.
Burk of Centerville, Michigan, there was an opening into the
anterior fornix from the bladder through which two fingers could
be passed. It required in all twenty shotted sutures to close the
opening. The results were perfect. In this case the fistula was
caused by long-continued pressure of the fetal head.
Should the anterior lip of the cervix be destroyed it will be
necessary to close the fistula by utilizing the posterior lip, when
the uterus will communicate with the bladder and the menstrual
blood will be discharged per urethram.
Vesico-uterine fistulæ must be dealt with in one of two
ways: First, if possible, the fistula is exposed by splitting the
cervix upon either side, when the opening into the uterus is
closed in the ordinary way; or, if the fistula cannot be so gotten
at, it will be necessary to obliterate the cervical canal and divert
the discharges from the uterus into the bladder.
Uretero-uterine and Uretero-vaginal Fistula. - These
forms of fistula occur so rarely that the reader is referred to
special works upon the subject for an extended description of the
534
A TEXT-BOOK OF GYNECOLOGY.
methods devised for dealing with them. Four cases were re-
ported during the year of 1891. The first two were by Schatz.*
He observed that the urine escaping from the ureter had a specific
gravity of from 1003 to 1006, while the specific gravity of that
passed per urethram was 1030. The urea was entirely absent from
the urine coming directly from the kidney and the solid matter
in the two urines was as I: 10. Campbellt succeeded in ac-
complishing a cure in one case by splitting up the uretero-vesical
septum and closing the vaginal surface of the cut. Dr. W. H.
Baker of Boston cured a similar case by dissecting up the
ureter, making an opening into the bladder near its neck, into
which the ureter was turned and the vaginal wound closed.
It may be necessary to remove the corresponding kidney, as
has been successfully done by Zweifel of Erlangen. A com-
pensatory hypertrophy of the opposite kidney usually takes
place.
Urethral Fistula.-There is ordinarily no difficulty in closing
artificial urethral fistulæ made for the purpose of curing or re-
lieving abnormal conditions of the urethra. There is, in these
cases, no loss of tissue, and the opening is closed by the same
methods required for the closure of ordinary vesico-vaginal fis-
tulæ. Should there be redundancy of tissue, as is sometimes
the case in dilatation of this canal, a sufficient amount may be
excised to overcome the existing distortion. The conditions
are, however, quite different when the urethra is partially or
entirely destroyed by sloughing or ulceration, as occasionally
The formation of an entire new urethra constitutes the
highest type of plastic surgery. For work done in this direction
the profession owes much to Dr. T. A. Emmet, to whose excel-
lent monograph on the subject the reader is referred.‡
occurs.
During the spring of 1891 I had to do with a case where the
urethra and the base of the bladder had been eaten away by
syphilitic ulceration. The patient was sent to me by Dr. Bowen
of Manistique, Michigan, and had previously been in the hands
of Prof. Nicholas Senn of Milwaukee. This distinguished sur-
* Medical Press and Circular, London, August 5, 1891.
† Virginia Medical Monthly, April, 1891.
"Vesico-vaginal Fistula," 1868.
URINARY FISTULÆ.
535
geon had, by three operations, succeeded in entirely restoring
the base of the bladder. The patient could retain her urine for
a short time by placing against the opening a tampon of cotton.
The tissues beneath the pubes had been greatly destroyed by the
ulcerative process. I succeeded by the following method in
making a new urethra: Two parallel surfaces about three six-
teenths of an inch wide, and extending from the natural site of
the meatus to the opening just beneath the arch of the pubes,
were vivified. An unscarified strip about half an inch in width
was left between them, to form the tract of the new urethra.
In order to approximate the two vivified surfaces it was neces-
sary to overcome the tension by making parallel to, and outside
of, each denuded line an incision into the mucous membrane.
At the point of the opening into the bladder the vivified sur-
faces were shaped in such a way as to adapt themselves to the
denuded edges of the fistula. The edges were next approxi-
mated by silver wire sutures over a small sized glass catheter,
which was kept in situ for seven days. The stitches were then
removed, but owing to the excessive tension (the width of the
unscarified surface should have been greater) the edges of the
wound corresponding to the middle third of the canal had not
healed. By a subsequent operation this opening was closed,
but the parts again separated sufficiently to leave a pin-head
fistula, which, however, does not leak urine. While the
patient now has very much better control of the bladder, the
results are not entirely satisfactory. She can retain the urine for
two or three hours, though it is still necessary to keep within the
vagina a tampon in order to press against the canal. Of course,
the vesical sphincter was entirely destroyed by the ulcerative pro-
cess and can never be restored. She is coming to me for another
operation and I shall undertake to narrow the canal at the vesi-
cal neck, hoping thereby to improve the retaining power of the
bladder.
Closure of the Vagina: Kolpokleisis.-This is an operation
which, happily, with the conquests of modern plastic surgery, is
rarely called for. Cases will, nevertheless, occasionally be met
with in which it is utterly impossible, because of the excessive
loss of tissue, or because of the changes within the vagina, to
536
A TEXT-BOOK OF GYNECOLOGY.
cure the fistula. Under these circumstances, in order to place
the patient in as comfortable a condition as possible, the vagina
will have to be closed. This operation is known as kolpokleisis.
The operation, as performed by Simon, consists of vivifying
transversely the walls of the vagina above the level of the ostium
vaginæ and bringing the denuded surfaces together with silver
wire sutures. Vidal de Cassis, who first introduced it, vivified
the inner surfaces of the labia majora and brought them together
by sutures. In the latter method the vulva is closed in an an-
tero-posterior direction, and there is necessarily a cleft below the
urethral orifice, through which the urine escapes; consequently,
it is useless.
Simon's method is as follows: The mucous membrane is
picked up with tenacula at a point where it is most lax; the
point selected should be as high as possible. The ring of tissue
to be removed is next outlined with the point of a scalpel, when
it is dissected from below upward with a pair of curved scissors.
It can ordinarily be removed in one continuous strip. The
sutures are introduced from above downward, i. e., carried
underneath the vaginal wound above and reintroduced upon the
inner border of the vaginal wound below, being brought out at
its outer edge. Care must be observed that neither the bladder,
the uterus, nor the rectum is injured by the needle. After all
of the sutures are introduced they are secured either with per-
forated shot or by twisting.
By this operation the bladder and the vagina permanently
connect with each other, and all of the discharges from the uterus
are made to pass through the urethra. This unnatural state will
necessarily give rise to more or less discomfort and the operation
is, therefore, never performed except as a last resource. Owing
to the fact that there will be more or less urine retained within
the vagina, there is danger of the formation of urinary concre-
tions. Usually, however, the patient is infinitely more comfort-
able than she would be were she compelled to go through life
constantly wet by the urinary discharge.
CHAPTER XXXV.
FECAL FIstulæ.
Fecal fistulæ do not occur so often as do the urinary. When
they do occur they are, because of the incontinence of feces
and gas, more distressing than are fistulæ giving rise to inconti-
nence of urine only.
Varieties. These are recto-vaginal, recto-labial, entero-
vaginal, and entero-vesical. The frequency of these several
varieties is in the order given.
The causes are much the same as those responsible for uri-
nary fistulæ, prolonged pressure and injuries during childbirth
being the most frequent cause. Cancerous and syphilitic ulcer-
ation oftener involve the posterior than the anterior vaginal wall.
Other causes are: direct injury, improperly fitted pessaries,
stricture of the rectum with retention of fecal matter, and ab-
scess of the recto-vaginal wall.
RECTO-VAGINAL FISTULÆ.
These are divided into recto-vulvar, inferior recto-vaginal, and
superior recto-vaginal, according to their situation. They vary
in size from an opening barely large enough to admit a fine
probe to one through which one or more fingers can be passed.
Those situated in the posterior vaginal cul-de-sac are especially
liable to be large. The edges are usually clearly defined, and
are hard and unyielding.
Symptoms and Diagnosis.-The patient will first be made
conscious of the existence of the fistula by the escape of fecal
matter and gas through the vagina. The amount of fecal mat-
ter which escapes in this way will depend upon the size of the
opening through the recto-vaginal wall, and upon the direction
of the fistula. If oblique, it may give rise to trouble only when
there is diarrhea. The existence of these symptoms will at once
suggest a fecal fistula and will call for an examination.
537
538
A TEXT-BOOK OF GYNECOLOGY.
Physical Signs.-In order to detect the opening the patient
should be placed upon her back in the lithotomy posture and
the posterior vaginal wall exposed. This can be done either by
means of the blade of a small-sized Sims speculum passed from
above, or, better still, by the introduction of an expanding
bivalve rectal speculum. If the opening is at all large its loca-
tion will be readily seen; if very small, on the other hand, it
may be necessary to inject into the rectum milk or some col-
ored fluid and watch for its appearance through the vagina.
Sometimes when there is much relaxation of the ostium
vaginæ air will pass into the vagina when the patient lies upon
her side, and its expulsion will give rise to suspicions of a fecal
fistula. The only way of determining positively whether or not
the air escapes from the bowel into the vagina is by physical ex-
ploration; there would, of course, be no odor attending the ex-
pulsion of flatus which finds its way into the vagina through its
ostium.
Prognosis. The prognosis, as in urinary fistula, will depend
both upon the size of the opening and its location. Those
most easily dealt with are located above the sphincter ani mus-
cle; those most difficult to contend with are located near the
perineum and involve this muscle. If the vagina is distorted by
cicatrices, the difficulty of accomplishing a cure is much in-
creased.
Treatment. It is sometimes possible to cure very small
recto-vaginal fistula by cauterization. An attempt should be
made to do this before subjecting the patient to an operation.
However, if the opening is of some size, the only resource is
denudation and coaptation with sutures. Wound infection,
because of fecal contamination, occurs much oftener than is the
case with urinary fistulæ. The operation may be performed
through the vagina or the rectum, or by flap-splitting through
the perineum.
Operation through the Vagina.-The cases especially suit-
able for this procedure are those not complicated by cicatrices.
The bowels should be thoroughly emptied by purgatives, and an
hour or two before the operation the lower bowel should be
washed with an enema, followed by a saturated boracic acid
FECAL FISTULE.
539
solution. The usual methods of cleansing the vagina are to be
observed. The posterior vaginal wall is now exposed by
placing the patient in the lithotomy posture and opening the
vagina with a Fritsch speculum introduced under the pubes.
Lateral retractors more thoroughly expose the field of operation.
The edges of the fistula are next denuded according to the
method recommended for vesico-vaginal fistula. The denuda-
tion may or may not extend into the rectal mucous membrane,
depending upon circumstances. Ordinarily, I think it is best to
go deep enough to include this membrane. The sutures are
passed in such a way as to include all of the tissues of the
posterior vaginal wall, unless the rectal mucous membrane has
not been denuded; in the latter event they extend only down
to it. The sutures are secured either by twisting or by per-
forated shot, as the operator may prefer. In making the
denudation and in introducing the sutures, the direction of the
suture line should be such as to produce the least amount of
traction upon the tissues when the sutures are secured. In very
large fistulæ this will oftener be transverse.
Operation through the Rectum. - As regards preparation,
the precautions given for the vaginal operation should be
observed. After the patient is placed in the proper position the
sphincter muscle is paralyzed by forcible divulsion. The rectal
cavity is next exposed by a suitable speculum, or by the blades
of two small Sims's specula. The denudation should extend for
some distance into the rectal mucous membrane, and should
include that of the vagina as well. The sutures are passed from
the rectal side, penetrate the vagina about half a centimeter from
the edge of the wound, and are reinserted the same distance.
upon its opposite side, making their appearance at a correspond-
ing point in the rectum. They may, however, be passed from
the vaginal side. If the latter method is resorted to, silver
wire may be used; whereas if the sutures are secured through
the rectum, silk is the preferable material, because of the diffi-
culty attending the removal of silver wire from this canal.
Perineal Operation.-The perineal method is especially
adapted to fistulæ situated near the perineum within the grasp
of the sphincter muscle. When so situated it is difficult to
·
540
A TEXT-BOOK OF GYNECOLOGY.
overcome the spasmodic tendency of the sphincter muscle by
divulsion alone. It is, therefore, necessary to cut entirely
through the perineal body, or what is left of it, when the condi-
tion is treated as a complete laceration of the perineum extending
upward into the vagina. It can be closed either by the flap-
splitting method, or by the older one of uniting the upper and
lower edges of the wound with interrupted or with continuous
sutures. Personally, I prefer the flap-splitting method.
After-treatment.—The patient is placed in bed and kept
perfectly quiet until the sutures are removed-at the end of
eight or ten days. The diet should be light and the bowels
confined for the first four days by administering a small dose
of opium. On the evening of the fourth day they are moved
by a cathartic and the lower bowel carefully emptied with an
enema. They are again confined for forty-eight hours, at the end
of which time they are moved as before. If the metallic sutures
are used, they can be left in for an almost indefinite length of
time, though it is usually best to remove them at the end of the
tenth day. Silk sutures should not be left in longer than eight
days.
RECTO-LABIAL FISTULEÆ.
In this variety of fistula the opening, instead of extending
into the vagina, finds its way through one or the other labium.
In order to cure it, it is necessary to lay the canal freely open
and destroy the sinus, either by dissecting it out entirely or by
curetting and closing the tract from the bottom. If practicable,
the sinus should be closed by the buried catgut suture; if not, it
should be packed with gauze and permitted to heal by granula-
tion.
ENTERO-VAGINAL FISTULÆ.
The usual cause of these fistulæ is extensive destruction of
tissue attending childbirth, there being left an opening into the
peritoneal cavity through one of the fornices of the vagina. A
loop of intestine may find its way into this opening and become
strangulated, giving rise to fistula. This accident may also attend
suppurating extra-uterine pregnancy and dermoid cysts. Can-
cerous ulceration sometimes perforates the peritoneal cavity and
FECAL FISTULÆ.
541
may likewise give rise to entero-vaginal fistula, though the
condition is rarely due to this cause.
Symptoms and Diagnosis.-If the opening is large, all
of the fecal matter will pass through the vagina and none
through the rectum. It is easily detected upon digital examina-
tion and can readily be seen by the introduction of a speculum.
If the discharge proceed from the small intestine, it will be of a
liquid character and of a greenish or yellowish color. If, on
the other hand, the connection is with the large bowel lower
down, it will be more solid and more characteristically fecal
in every way.
Treatment. It will be necessary to close the opening
through the vagina, as it cannot be reached through the rectum.
If small, an attempt may be made to close it by cauterization,
a method which will often be successful; if, however, the open-
ing is large, and all of the fecal matter passes into the vagina,
the only resource is laparotomy and resection of the intestine.
Before doing this the operator must make sure that the rectum
and lower bowel are pervious.
Should this operation fail, or should the patient decline to
submit to it after a full understanding of the dangers attending
it, kolpokleisis may be performed. Before the vagina is closed,
however, it is necessary to make a communication between it
and the rectum below the fistula. The opening is best made by
compressing the recto-vaginal septum in the jaws of long
curved forceps, one blade of which is passed into the vagina and
the other into the rectum. The compression is continued long
enough to produce adhesions and to create a slough. After the
slough comes away an opening sufficiently large to permit the
fecal matter to pass from the vagina into the rectum is created.
Kolpokleisis is then performed according to Simon's method,
which is described in the preceding chapter.
ENTERO-VESICAL FISTULÆ.
Suppuration within the pelvis, from whatever cause, may give
rise to a communication between the intestine and the bladder.
This is exceedingly rare, but cases of the kind are occasionally
recorded. The amount of suffering caused by it will depend
542
A TEXT-BOOK OF GYNECOLOGY.
upon the size of the opening and the portion of the bowel which
connects with the bladder. When air finds its way into the
bladder the condition is known as pneumaturia. Should the
opening be small and the inconvenience not great, the physician
will hardly be justified in subjecting the patient to an abdominal
section or to suprapubic cystotomy for the purpose of closing it.
Should, unfortunately, the opening be large, the urine will be
contaminated by fecal matter, which will very soon give rise to
cystitis and renal disease. Here the wretched condition of the
patient will warrant either laparotomy or suprapubic cystotomy;
or, if these be impracticable, high colotomy. The site of the in-
testinal opening can be surmised by the character of the discharge
which finds its way into the bladder and is passed per urethram.
Should the connection be with the large intestine low down,
this fact may be determined by injecting milk into the bladder and
watching for its appearance through the rectum.
CHAPTER XXXVI.
DISPLACEMENTS OF THE UTERUS.
General Considerations.-In dealing with uterine displace-
ments it must be borne in mind that the uterus is a movable
organ. This fact has given rise to much discussion as to its
normal position. The fundus is pushed forward by a distended
rectum and backward by a distended bladder; the entire organ
is made to descend by intra-abdominal pressure, and is elevated
during coitus. The displacements resulting from a distended
bladder are well shown in Fig. 101.
It will be seen that, with the bladder empty, the axis of the
uterus is very nearly at a right angle with the axis of the vagina;
the fundus rests upon the bladder and is close to the symphysis
pubis. The body, because of the rectum, is slightly deviated to
the right and is bent more or less forward; the cervix is directed
backward.
The uterus is supported by—
Uterine ligaments;
Intrapelvic areolar tissue and pelvic walls;
Supporting power of the abdominal walls;
Upper part of vagina.
The varieties of displacement which present themselves for
consideration are:—
1. Anteversion, in which the fundus is directed unnaturally
forward and the cervix unnaturally backward; the normal
uterine curve is less pronounced.
2. Anteflexion, in which the normal curve is increased; the
direction of the cervix is but little changed.
3. Retroversion, in which the fundus is directed backward and
the cervix forward.
4. Retroflexion, in which the uterus is bent upon itself, so that
its normal curve is reversed; the direction of the cervix is
normal or nearly so.
1
543

544
A TEXT-BOOK OF GYNECOLOGY.
5. Lateroversion, in which the uterus is drawn to one side.
6. Displacement of the uterus as a whole-retroposed. This
may result from pelvic tumors or from inflammatory adhesions.
7. Prolapse, usually associated with more or less prolapse of
the vagina.
FIG. 101.
VARIATIONS OF THE POSITION OF THE UTERUS CAUSED BY THE VARIOUS DEGREES
OF BLADDER DISTENTION.
8. Ascent, the result of traction from above (ovarian and
fibroid tumors).
9. Inversion.
Rarely does one form of displacement exist alone. Thus,
anteversion and anteflexion are always combined, as are retro-
DISPLACEMENTS OF THE UTERUS.
545
version and retroflexion. More or less descensus is usually
associated with the retro-displacements, and a slight lateral dis-
placement is frequently combined with the other forms.
ETIOLOGY.
The causes of the several forms of uterine displacements are
numerous. Any condition or disease giving rise to increased
weight of the organ tends to produce displacement. Such are
the various forms of inflammation-acute and chronic-subinvo-
lution, tumors, pregnancy, etc.
The natural supports of the uterus are diminished by relaxa-
tion of the uterine ligaments, injuries to the perineum and pelvic
floor, flabby and over-distended abdominal walls, and an abnor-
mally large pelvis.
The causes acting from above are :—
Increased intra-abdominal pressure, the result of pelvic and
abdominal tumors or ascites;
Constriction of the waist by improper clothing;
Straining or lifting ;
Undue distention of the bladder and colon.
Pelvic inflammation, giving rise to distortion of the pelvic
organs in general, may cause any of the forms of uterine dis-
placement. When resulting from inflammatory exudates, the
displacement is at first due to the mechanical pressure of the
exudate, and, later, to its retraction. Thus an exudate in the
right broad ligament will primarily push the uterus to the oppo-
site side; after retraction occurs the fundus will be drawn toward
the side of the exudate. Anteversion and anteflexion are fre-
quently caused by retraction of the utero-sacral ligaments-the
sequelae of previous inflammation.
SYMPTOMS.
The symptoms characterizing the special displacements will
receive due attention later on. A few general considerations
are worthy of notice at this time.
I have elsewhere called attention to the fact that uterine dis-
placements are ordinarily attended with no distress unless asso-
35
546
A TEXT-BOOK OF GYNECOLOGY.
ciated with hyperemia or hyperesthesia.* That is to say, save in
acute cases which are the result of traumatism, uterine displace-
ments will and frequently do exist for an indefinite period without
giving rise to the least discomfort. This is especially true of
congenital anteversion and anteflexion-so emphatically so that
some eminent authorities deny that these displacements ever
require treatment.
It is an indisputable fact that many women go through life
with the various forms of displacement without being conscious
of their existence. If married they may have been sterile, but for
this symptom they have never submitted to a local examination.
In the larger number of cases, however, either hyperesthesia
or hyperemia, or both combined, are sooner or later developed.
Then a train of symptoms, more or less intense, succeeds.
These symptoms are by no means constant nor are they pathog-
nomonic. The hyperemia, after continuing for a certain length
of time, usually gives rise to hyperplasia and chronic metritis.
The increased weight resulting from the uterine congestion
aggravates the displacement, in whatever form it may be. In
this way the uterus is "blood-logged," as it were, and asso-
ciated with the displacement there is usually more or less.
prolapse. As time goes on the mucous membrane undergoes
hypertrophy, which in turn establishes menorrhagia or metror-
rhagia. Dysmenorrhea is likewise a frequent symptom of uterine
displacement, especially of anteflexion. It is due both to ob-
struction and to the congestion and hyperesthesia incident to the
displacement. Instead of excessive menstruation there may be
amenorrhea, particularly in congenital anteflexions. As already
intimated the cervical stenosis, which is an essential feature of
flexion, is one of the most common causes of sterility. Dyspar-
eunia also results in a goodly number of cases. All forms of
displacement may give rise to distress upon locomotion. Sacral
and lumbar pain and reflex pains in various parts of the body
are of common occurrence. In perimetritis, salpingitis, etc.,
the uterus is usually fixed by adhesions.
It will thus be seen that the symptoms of uterine displace-
* v. Chapter viii.
ANTEVERSION AND ANTEFLEXION.
547
ment, when such symptoms exist, are general rather than specific;
and that they may be entirely wanting. It will not do, therefore,
to undertake the erection of a special uterine pathology based
upon displacements, as has actually been attempted by Hewitt
and others; nor will it do to ignore the importance of uterine
displacements because in a goodly number of cases no inconve-
nience follows in their train.
ANTEVERSION AND ANTEFLEXION.
In anteversion the womb is tilted forward without any bend in
its axis; in anteflexion it is not only tilted forward but it is also
bent upon its axis.
its axis. These two conditions are frequently of con-
genital origin. Any of the symptoms which have been enumer-
ated may result from either form of displacement. Since, how-
ever, they are oftener congenital it is hardly wise to exaggerate
their importance. The physician is liable to attribute to them,
if he can discover no better cause, symptoms which are in reality
due to nerve exhaustion, irritable spine, congestion of the ovary,
etc. It is well, to be sure, to look to the displacement when an
intractable dysmenorrhea or amenorrhea exists. So, too, if rectal
and vesical tenesmus, especially the latter, do not yield to
ordinary treatment. I have in another place (page 68) referred
to the importance of looking for antedisplacement, particularly
when the result of shortening of the utero-sacral ligaments, when
there exists an obstinate dysuria which is clearly not due to in-
flammation of the bladder or urethra. Ovarian congestion and
ovaritis may result from the embarrassed uterine circulation.
Diagnosis. In anteversion digital examination will reveal the
cervix in the hollow of the sacrum, and directed more posteriorly
than normal. The finger will detect in the anterior fornix the
fundus uteri, which is continuous with the cervix. Upon bi-
manual examination the entire organ can be gotten between the
two hands and clearly outlined. There is no sulcus just behind
the internal os, as in anteflexion. Should doubt still exist, after
the possibilities of pregnancy are eliminated, the uterine sound
may be used. The introduction of this instrument will require
some tact because of the backward displacement of the cervix.
If necessary the cervix can be drawn down with the volsella or
}

548
A TEXT-BOOK OF GYNECOLOGY.
tenaculum, which will facilitate its introduction. No force should
be attempted in passing the sound. The handle will have to be
carried well back and the instrument given various degrees of
curvature before it will penetrate the uterine cavity. By the aid
of the sound it is usually possible to distinguish an antedisplaced
fundus from a small fibroid tumor, or inflammatory deposits in the
anterior cul-de-sac (Fig. 102).
In anteflexion the fundus is felt more distinctly in the anterior
fornix than is the case in anteversion. The cervix, instead of
DOD
FIG. 102
ANTEVERSION OF THE UTERUS.
E. G.
being directed backward, is directed downward and even forward.
By sweeping the finger along its anterior surface there will be
felt a sulcus separating the body from the cervix. Occasionally
the cervix at the point of flexure is drawn so far anteriorly as to
give rise to a condition resembling partial retroversion or
retroflexion. The uterus may be low in the vagina. The
sound will have to be bent much more acutely in order to pene-
trate the uterine cavity than is the case in simple version. It is

ANTEVERSION AND ANTEFLEXION.
549
necessary to give to the instrument a curve corresponding to
the degree of flexion before it can be passed. By it the location
of the fundus can be determined, as well as its mobility and sensi-
tiveness (Fig. 103).
By practising the bimanual with the sound in the uterus
the examiner can also satisfy himself that the tumor in the
FIG. 103.
ANTEFLEXION OF THE UTERUS.
A half-section of the pelvic viscera of a sterile woman, aged 33. The uterus is small,
with its body considerably anteflexed on the cervix, which is very short, the
vaginal portion hardly existing, so that the Douglas cul-de-sac lies below the
os externum. The bladder coats are hypertrophied. The cervix is drawn back-
ward by contraction of the utero-sacral ligaments. (Museum R. C. S., Photo-
graphed by the Author.)
anterior fornix is not a small fibroid.
Should there be diffi-
culty in passing the instrument, the axis of the uterus can be
straightened, as in anteversion, by drawing the cervix down-
ward with the volsella; or by pushing the fundus upward
through the anterior vaginal fornix.
Before the examination is concluded it is well to carefully
550
A TEXT-BOOK OF GYNECOLOGY.
1
explore the vaginal roof for the evidences of adhesions, con-
stricting bands, or inflammatory effusions. The mobility of the
uterus should always be ascertained before an attempt is made to
reposit it with the sound.
Anteversion and anteflexion are so inseparably blended that I
have deemed it wise to consider the two affections conjointly.
In most cases anteversion precedes anteflexion, and often neither
condition is suspected until after marriage, when the patient may
find herself sterile. In dealing with dysmenorrhea in young girls
these two forms of displacement, as possible causes, should always
be borne in mind.
TREATMENT.
It is by no means necessary to treat all, or even a majority, of
cases of antedisplacement. Certainly no treatment is called
for unless distressing symptoms exist. The principles of
treatment are the same in both forms, though it is more
difficult to overcome anteflexion than anteversion. In either
variety the deformity is less easily corrected than is the case
with retrodisplacements. In order to elevate the fundus with a
pessary it is necessary to exert more or less pressure through
the bladder. This will frequently give rise to distress, and
many times the patient can better tolerate the disease than the
treatment.
In all instances the cause should be removed if possible. This
implies the adoption of proper clothing,—all constrictions about
the waist being overcome,—the relief of pelvic congestion due
to constipation or irregular sexual habits, the removal of inflam-
matory exudates by proper treatment, and the stretching, if
contracted, of the utero-sacral ligaments by uterine massage and
pressure exerted by tampons.
A certain amount of preparatory treatment is usually necessary
before a pessary is fitted. This consists in the application of
those measures having for their object the relief of pelvic con-
gestion and inflammation. The hot douche, the medicated
tampon, and proper rest will afford much relief. It is not only
useless but dangerous as well for the patient to undertake to
wear a pessary while suffering from pelvic inflammation, even of a
ANTEVERSION AND ANTEFLEXION.
551
chronic type. Properly applied tampons placed in the anterior
vaginal fornix will so elevate the fundus and the uterus as to
afford marked temporary relief. After the parts are prepared by
this treatment a pessary may be fitted.
While the patient is undergoing preparatory treatment an effort
should be made to straighten the uterus. This may be done
either by the bimanual or by the use of the uterine sound or
repositor. If done according to the former method, the fundus
is lifted by pressure exerted through the anterior fornix and by
drawing the cervix toward the symphysis. Should there be no
adhesions but little difficulty will be experienced in repositing the
uterus in this way. On the other hand if the utero-sacral liga-
ments are contracted, or if the fundus is attached in front by
adhesions, it will be impossible to correct the displacement.
However, repeated attempts to do so, care always being observed
not to use undue force, will in time stretch the adhesions suffi.
ciently to make reduction possible. This is a form of uterine
massage which, if intelligently applied, may result in much
good.
When the reposition is made by means of the uterine sound,
the instrument should be introduced as far as the fundus and
curved sufficiently to insure its introduction. The finger of
the left hand should now serve as a fulcrum at the center of the
sound, when the handle is carried forward toward the symphysis,
the fundus being thus retroverted. Finally the sound is carefully
rotated (v. p. 108) and a slight retroflexion induced. Of course
no attempt should be made to reduce the displacement by
means of the sound if the uterus is fixed by adhesions.
Various forms of uterine repositors have been devised for this
especial purpose, but none is superior to the uterine sound if
skilfully used.
Pessaries in Antedisplacements.-Undoubtedly pessaries
in all forms of displacement have been used much too often. This
fact has led some writers to make a sweeping condemnation of
them, especially in antedisplacements. Ingenuity and mechani-
cal skill are essential requisites in fitting pessaries. Without
these much harm may be done. If the physician possesses these
qualities he will be able, in all forms of displacement, to do much
552
A TEXT-BOOK OF GYNECOLOGY.
good with pessaries. However, to obtain the best results careful
discrimination is necessary. No two cases can be treated in
exactly the same way. A pessary must be selected that will lift
the body of the womb by pressure exerted through the anterior
fornix without injuring the bladder, at the same time drawing the
cervix forward by obliterating the utero-vesical pouch.
For this purpose the most frequently employed pessaries are
Gehrung's, Hewitt's, and Thomas's. Gehrung's is simply a
Hodge pessary doubled upon itself. Its two lateral curves
rest on the floor of the pelvis, while its superior and inferior
arches impinge upon the anterior vaginal fornix, between the
fundus uteri and symphysis. This is the manner in which it is
used by Mundé, and is, I believe, the preferable way of insert-
ing it. Gehrung himself fits it so that it rests "with its whole.
FIG. 104.
FIG. 105.


EMANN.CA
TIEMANN-CO
GRAILY HEWITT'S ANTEVERSION
PESSARY.
THOMAS'S ANTEVERSION BUCKLE
PESSARY.
lower arch on the floor of the pelvis, the uterus reclining against
its superior curve." My observation leads me to believe that
even if the instrument is introduced, as recommended by
Gehrung, it will in nine cases out of ten assume the position
described by Mundé. In this position it does not interfere with
coitus.
Graily Hewitt's anteversion pessary is shown in Fig. 104.
One point of it rests on the vaginal floor near its entrance, and
one high up behind the cervix uteri. Its apex presses the ante-
rior vaginal fornix upward, thus elevating the fundus both by direct
pressure and by shortening the anterior vaginal wall. This pes-
sary is made in three sizes, and will sometimes afford relief
when other instruments fail in their object.
ANTEVERSION AND ANTEFLEXION.
553
Thomas's anteversion buckle pessary is very popular (Fig.
105). It is a modification of Hodge's lever instrument. The
pessary is introduced closed, and as the upper arch approaches
the cervix the posterior bar is directed into the posterior fornix,
while the anterior bar is pushed forward by the finger. The
displacement is overcome by the uterus
riding between the posterior and the mov-
able bar.
Fig. 106 represents Thomas's open cup
anteversion pessary. It is introduced with
the movable bar extended. This bar is
then thrown forward and the uterus rests
in the concave portion of the cup.
FIG, 106.

GJIEMANN & CO
THOMAS'S OPEN-CUP
ANTEVERSION PESSARY.
Stem pessaries, while the only ones that
really overcome the flexion, are too dan-
gerous to be resorted to except after
divulsion; the patient is then kept absolutely at rest for at least
a week. For this purpose I use Cleveland's glass plug. (v. p. 270.)
The benefit derived from the use of vaginal pessaries in
flexions is due quite as much to the elevation of the entire uterus,
thus relieving the embarrassed circulation, as to the straightening
of the organ.
Whatever form of vaginal pessary is selected there are certain
dangers to be borne in mind. When left in the vagina for a long
time uncleaned they become incrusted with calcareous matter,
and may set up serious ulceration, and even bury themselves in
the tissues. Cellulitis and metritis have more than once
resulted from their use. No pain should result from a properly
fitted pessary. This fact should be impressed upon the patient
and she should be instructed to have it removed at once should
pain occur. This precaution will largely remove the element of
danger. Frequent cleansing douches are to be advised. The
proper size of the pessary is to be determined by the shape and
capacity of the vagina. It is better to run the risk of selecting
too small an instrument than to insert one too large. After its
introduction the patient should be directed to walk across the
room once or twice, after which an examination should be made
in the upright posture. If the pessary has turned it is too small,
and a larger one should be substituted. (v. p. 560.)
554
A TEXT-BOOK OF GYNECOLOGY.
RETROVERSION AND RETROFLEXION.
We have seen that physiological retroversion of the uterus
occurs whenever the bladder is distended. The displacement
becomes pathological only when the fundus remains persistently
directed toward the hollow of the sacrum. When the body of
the uterus becomes bent upon itself so as to form an angle,
flexion is added to the version. It is, then, entirely possible
to have a retroversion without a flexion; on the other hand,
a retroflexion is always combined with version, the latter in
nearly all instances preceding the former.
Etiology. The predisposing causes are those of uterine dis-
placements in general. The exciting causes are: increased intra-
abdominal pressure and diminished uterine support; increased
uterine weight from congestion, tumors, etc.; and traction upon
the uterus from below.
It will be observed that the various exciting causes are those
which are associated with and attend parturition. Injuries to
the pelvic floor, subinvolution, and chronic metritis all tend to
congest the uterus and to increase its weight. If, now, the
fundus is crowded into the hollow of the sacrum by a tightly
applied obstetric bandage, a retrodisplacement is almost
certain to result. Unlike antedisplacements, retroversion and
retroflexion occur much oftener in women who have borne
children.
Pathology. The size of the uterus is nearly always
increased because of the embarrassed circulation, and not
infrequently there is chronic inflammation of both its par-
enchyma and its lining membrane. The fundus finds its way
into the pouch of Douglas, and in marked retroflexion may
depress this pouch as far as the pelvic floor; it is also in contact
with the anterior surface of the rectum. The external os is
patulous, and in women who have borne children the cervix is
usually more or less lacerated. The anterior surface of the
broad ligaments looks backward and downward, while the utero-
sacral ligaments are stretched by the cervix being directed
anteriorly. Not infrequently one or both ovaries are displaced
with the uterus and may find their way into the posterior cul-
de-sac. The ureters may be so compressed as to give rise to
RETROVERSION AND RETROFLEXION.
555
dilatation.* The bladder is not so markedly affected as it is in
antedisplacements. If the displacement is the result of, or has
been followed by, pelvic inflammation, the fundus is usually
fixed by adhesions.
Symptoms. These, as in antedisplacements, may be entirely
wanting, or of the most marked character. Probably the most
constant symptom is a feeling of weakness and pain in the back,
especially after being upon the feet for some time. Other mani-
festations of the displacement are caused by the congestion and
inflammation resulting from the embarrassed circulation. There
is a sensation of bearing down and heaviness in the pelvis with
more or less rectal tenesmus. Constipation and hemorrhoids
may likewise result from rectal pressure. Menorrhagia and
leucorrhea, due to endometritis, are not infrequently present.
Any of the so-called "hystero-neuroses" may develop. Dys-
menorrhea is much less common than in antedisplacements for
the reason that the cervical canal is usually increased instead of
diminished in caliber. Pelvic pain due to pressure upon the
nerves is often most distressing and not infrequently ex-
tends to the lower extremities. Dyspareunia, sterility, and
uterine colic are symptoms of less constant occurrence. When
conception does take place abortion frequently results.
Diagnosis. In retroversion the cervix will be found lower
than normal in the vagina and directed forward. By carrying
the finger along the posterior surface of the uterus no sulcus
can be felt, as in retroflexion. The bimanual will fail to locate
the fundus in front. The uterine sound will determine the
direction of the canal.
* I have at the present time under observation a most interesting case in which
obstruction of the ureter was evidently caused by the pressure of a retroverted fundus.
The patient was referred to me by Dr. S. A. Boynton of Cleveland. For years she
had suffered from attacks of intense pain in the region of the right kidney. During
these attacks a tumor of some kind formed, which resembled in every particular an
enlarged floating kidney. It formed quickly, becoming fully as large as a fetal head,
and then subsided quite as quickly, after which the quantity of urine was markedly in-
creased. For the last year these attacks occurred as often as once or twice a week,
and were usually brought on by undue exercise. On bimanual the uterus was found
retroverted and enlarged. I fitted a Hodge pessary nine weeks ago, since which time
she has remained perfectly well. Whether or not permanent relief has been obtained
remains to be seen.
556
A TEXT-BOOK OF GYNECOLOGY.
In retroflexion the cervix may be normally located; it is
usually, however, lower in the pelvis than it should be and looks
directly downward. In the posterior fornix the fundus of the
uterus will be felt as a rounded body separated from the cervix
by a sulcus. The bimanual shows the fundus absent in front.
The sound will require a sharp posterior curve in order to insure
its introduction. In both forms of retrodisplacement the fundus
can be felt through the rectum; it is, however, lower down,
and more readily palpated in retroflexion.
The several affections giving rise to a tumor in the cul-de-sac
of Douglas, and hence liable to be confounded with the retro-
displacements, are:-
Prolapsed ovary or a small ovarian tumor;
Small myoma in posterior uterine wall;
Inflammatory exudates;
Fecal accumulation.
In none of the foregoing affections will the sound penetrate the
tumor, as it will in the case of a retrodisplaced fundus. Other
differentiating points will be considered seriatim.
Prolapsed Ovary or a Small Ovarian Tumor.-A prolapsed
ovary is exquisitely sensitive and pressure upon it gives rise to
a peculiar sickening pain. It is much smaller than the fundus
uteri and, unless adhered, more mobile. When a small ovarian
tumor occupies the cul-de-sac of Douglas the fundus will be
found in front.
Small Myoma in Posterior Uterine Wall.-Bimanual should be
practised with the sound in the uterine cavity. The presence of
the tumor can then be detected by digital examination per
rectum. The fundus is directed forward.
Inflammatory Exudates.-The uterus is more or less fixed.
There is a history of preceding inflammation.
Fecal Accumulation.-This pits upon pressure. In case of
doubt the rectum should be emptied.
Prognosis. In considering the prognosis of retroversion and
retroflexion of the uterus it is necessary to note the presence or
absence of adhesions, the duration of the displacement, and also
the presence or absence of such complications as prolapse of the
ovaries, chronic metritis and salpingitis, injuries resulting from

RETROVERSION AND RETROFLEXION.
557
parturition, etc. In uncomplicated retroversion the uterus can
usually be restored to its normal position by a properly fitted
pessary. Flexions are more difficult to contend with, though by
partially overcoming the displacement and elevating the entire
organ marked relief is often afforded. As a last resort, some of
the operations presently to receive consideration may be utilized.
FIG. 107.
RETROVERSION OF THE UTERUS WITH A VERY SLIGHT DEGREE OF FLEXION.
(Museum R. C. S., Photographed by the Author.)
Treatment.-The same preparatory measures recommended
for antedisplacements are necessary. No attempt should be made
to reposit the uterus if acute pelvic inflammation is present.
When the fundus is fixed by inflammatory adhesions, these may
be cautiously stretched by pelvic massage. If a cervical lacera-
tion is perpetuating the uterine congestion it should be repaired.
558
A TEXT-BOOK OF GYNECOLOGY.
Injuries to the pelvic floor are likewise to be overcome by proper
operative procedures.
Frequent reposition of the uterus previously to fitting a pes-
sary will do much good. It may be accomplished by one of the
three following methods:-
1. Bimanual Recto-vaginal Manipulation.-With the patient in
the dorsal or Sims posture the fundus is pushed forward with the
finger of one hand in the rectum, while the cervix is drawn
backward with the finger of the other hand in the vagina.
2. Genu-pectoral Posture.-In this position intra-abdominal
pressure is reduced to a minimum and gravity alone may carry
the fundus forward. It is, however, usually necessary in addition
to push the fundus upward either through the vagina or rectum;
or to pull the cervix downward, so as to permit the fundus to
FIG. 108.
FIG. 109.

32
HODGE'S CLOSED LEVER PESSARY.

1.TIEMANN & CO.
THOMAS'S RETROFLEXION PESSARY.
escape from the hollow of the sacrum. As a palliative measure
the genu-pectoral posture practised for five minutes twice a day
will often do much good.
3. The Uterine Sound or Uterine Repositor.-Care must be ob-
served not to exert too much force with these instruments. The
sound should be used as straight as possible and cautiously turned
within the uterus. (v. p. 108.)
Retention by Means of Pessaries.—Retrodisplacements can
be much more readily overcome by means of a pessary than can
antedisplacements. This is because injurious pressure is not
exerted upon the neighboring organs when the posterior vagi-
nal wall is stretched. The principle of a retroversion pes-
sary, such as the Hodge, is this: The posterior vaginal wall is
carried upward by the instrument and its upper bar gives a
RETROVERSION AND RETROFLEXION.
559
point d'appui to the posterior fornix. This draws the cervix back-
ward and throws the fundus forward, just as do the utero-sacral
ligaments normally. This will not overcome the flexion, but by
elevating the entire organ, as already observed, the obstructed
circulation is often so much relieved as to do much good.
FIG. 110.
The intra-vaginal, retroversion and retroflexion pessaries most
frequently used are Hodge's (Fig. 108), Thomas's (Fig. 109), and
Albert Smith's (Fig. 110). It will be observed that the principle
is the same in all. The original Hodge pessary was as wide at
its lower extremity as at its upper. Smith's modification con-
sisted of narrowing the lower end so as to conform to the shape
of the vagina. This is a
valuable improvement.
Thomas's modification the
upper bar is made bulbous
and the sacral curve is exag-
gerated. In certain cases it
can be tolerated when the
other forms cannot be.
In

G.TIEMANN & CO
ALBERT SMITH'S PESSARY.
These pessaries are now
made almost altogether from vulcanite, which is light and unaf-
fected by the vaginal discharges. The application of heat renders
them flexible, and it is therefore possible to mold them into any
desirable shape. This is done as follows: Place the pessary in
hot water; leave for five or ten minutes; remove and mold into
the shape desired and then set by immersing in cold water.
It may be molded by first smearing the pessary with vaselin
and then heating it over a spirit lamp. When the latter method
is employed care must be taken not to burn the vulcanite, which
will leave its surface rough and irritating.
All of the foregoing pessaries are made in the form of an
elongated horseshoe. The curved upper end adapts itself to the
posterior fornix, while the curved lower end adapts itself to the
lower portion of the vagina. With its upper sacral curve and
lower pubic one it therefore corresponds to the vaginal slit, and
when within the vagina the concavity of the upper sacral
curve looks forward, while the concavity of the lower pubic one
looks backward. If properly fitted the vaginal walls grasp it
closely both anteriorly and posteriorly. Since, however, the
560
A TEXT-BOOK OF GYNECOLOGY.
posterior vaginal wall is narrower below than it is above, Albert
Smith's instrument is the more scientific. Thomas's modifica-
tion is especially adapted to those cases where the sacral curve
is very pronounced and the vagina long.
In fitting a pessary a digital examination should first be made
for the purpose of obtaining the dimensions of the vagina.
A pessary is then selected which will fulfil as nearly as possible
the requirements of the case. Should the sacral curve be very
pronounced the instrument should be molded accordingly.
Should the vagina be comparatively straight it may be necessary
to lessen this curve. The instrument should be shorter and nar-
rower than the posterior vaginal wall, so that no tension will be
produced when it is in position. The lower bar is then grasped
with the index finger and thumb of the right hand, the labia
separated with the fingers of the left, and the upper sacral curve
turned so that the pessary at its widest part will correspond to
the antero-posterior diameter of the vaginal outlet. It is kept
well pushed back toward the perineum, so as not to pinch the
tissues anteriorly between the pessary and the pubic bones.
After it has passed the ostium vaginæ the index finger is carried
under the lower bar and above the upper in such a way as to
convey the latter back of the cervix. Unless this precaution be
taken the upper bar will, in all probability, pass into the anterior
fornix instead of the posterior. When in place the lower end
should be just within the vaginal orifice. It is compressed be-
tween the posterior face of the pubic segment and the oblique
anterior face of the sacral segment. In this position the intra-
abdominal pressure acts nearly equally upon both the superior
and inferior bars, and the cervix is drawn backward with a cor-
responding elevation of the fundus. An examination should be
made in the erect posture before the patient leaves the consulting
If the pessary is too small it will show a disposition to
turn transversely; if it is too wide the patient will complain of
more or less tension and distress. The lower end should not
project below the pubic bones. It may be necessary to introduce
several instruments before a proper one is obtained. Experience
will, however, enable the physician in most cases to select one
of proper size and shape after one or two trials.
room.
Before leaving the office the patient should be instructed to
RETROVERSION AND RETROFLEXION.
561
return at once if the instrument causes pain. She should report
herself for examination in the course of three or four days to see
whether or not it keeps its proper position. After it becomes
evident that the pessary is perfectly fitted she may wear it for an
indefinite length of time without removing it. It is necessary
to resort to occasional cleansing injections whenever a pessary is
within the vagina. So far as any distress is concerned, the
patient should be entirely unconscious of its presence, nor
should it interfere with coition.
Cases are every now and then met with where, because of the
great weight of the uterus, or because of injury done to the pel-
vic floor and perineum, the ordinary intravaginal pessary will not
accomplish the desired end. It may then be necessary to utilize
an instrument suspended from the waist. For this purpose
FIG. III.
FIG. 112.


G.TIEMANN & CO.
G.TIEMANN&CO.
THOMAS'S CUTTER'S RETROVERSION
THOMAS'S CUTTER'S ANTEVERSION
PESSARY.
PESSARY.
Thomas's modification of Cutter's anteversion and retroversion
pessaries are the ones most generally used (Figs. 111 and 112).
All forms of extra-vaginal stem pessaries are objectionable,
and should be resorted to only when intravaginal support is
insufficient.
When the abdomen is unduly pendulous and large much relief
may be afforded by a properly fitting abdominal supporter.
It sustains the abdominal walls, lifts them upward, and changes
the direction of the intra-abdominal pressure. Those in most
common use are Hood's and the London Abdominal Sup-
porter.
In spite of the utmost skill in fitting pessaries cases will every
now and then be met with where any form of instrument will
fail to bring the desired relief. This may be due to relaxation
36
562
A TEXT-BOOK OF GYNECOLOGY.
of the perineum and pelvic floor, to laxity of the vagina, to
ovarian displacements, or to periuterine inflammation. If it is
probable that a cure can be accomplished by restoring the perin-
eum and pelvic floor to their normal condition, this should be
done. Indeed, before the more serious operations from above,
having for their object the correction of the displacement, are
resorted to reparation of the pelvic floor and perineum should
always be made. Failing to afford relief by these measures, and
failure will be the rule where the ovary is prolapsed with the
uterus, there are two operations, one or the other of which may
be utilized.
The first is known as the Alexander Operation. It was revived
by Alexander of Liverpool, although the idea of correcting retro-
displacements of the uterus by shortening the round ligaments
belongs, it is claimed, to Alquie of Montpellier. This operation
is especially applicable to backward and downward displace-
ments. After its revival by Alexander it enjoyed a certain
degree of popularity, but it has again fallen into disrepute. There
is, in the first place, great uncertainty in finding the round liga-
ments; and, unfortunately, the results are not permanent, the
displacement, in at least a goodly number of cases, becoming as
bad as ever after a certain length of time. I have performed the
operation in all ten times. Four of these cases were absolute
failures, because of my inability to find the ligaments, or because
of their deficient size when found. In one case but one ligament
was found. The five remaining cases were entirely successful.
However, the number of failures has led me, as it has led the
majority of specialists in this country, to discard the operation
for that of ventral hysterorrhaphy, or fixation of the uterus to
the anterior abdominal wall. I have in the dead-room examined
the round ligaments of a large number of subjects, and have studied
the technique of the operation under the personal demonstration
of a number of its warmest advocates. There is absolutely no
way of determining the size of the ligaments before the inguinal
canal is opened. If they are very small the most profound
anatomist will fail to find them. I shall, therefore, not take the
trouble to describe the technique of the operation. I shall like-
wise refrain from describing vaginal hysterorrhaphy, or fixation
RETROVERSION AND RETROFLEXION.
563
of the uterus through the vagina, because of the dangers
attending this method.
Gastro-hysterorrhaphy, or Ventral Fixation of the Uterus.
-This operation was first suggested by the fixation of the
pedicle of ovarian cysts outside the abdomen when this practice
was common. It was observed that this procedure corrected the
displacements of the uterus; hence the idea of fastening the
uterus to the abdominal wall for the sole purpose of overcoming
the displacements.
It is claimed that gastrohysterorrhaphy was performed for the
first time in 1869 by Koeberle. To Olshausen, however, is due
the credit of systematizing it. In this country Howard A.
Kelley, Polk, Wylie, Mundé, and others have been foremost in
popularizing it. Its value is now fully established.
Operative Technique.—The technique of the operation, simple
as it is, has been made difficult to comprehend by the operative
details insisted upon by most of the authors. I shall, therefore,
endeavor to give as simple a description of it as is possible.
The abdomen is opened in the median line as for oöphorec-
tomy. After separating any adhesions that may exist, the fundus
is pushed forward. The appendages are ablated or not, accord-
ing to the indications; if diseased, they are, of course, removed.
It is safer, I think, in ovarian prolapse to remove the displaced
ovary. A curved needle armed with silver wire is then carried
through the abdominal wall of the left side one half inch from its
border. It next penetrates the uterus opposite the insertion of
the two round ligaments as shown in Fig. 113.
The needle is carried under the peritoneum and through the
superficial layer of muscular tissue to the extent of a quarter of
an inch, when it penetrates the abdominal wall of the opposite
side from behind forward and is brought out on the skin surface.
A second suture is introduced above this and, if necessary, a
third. Usually, two are sufficient.
After the introduction of the sutures, the anterior uterine sur-
face over the area occupied by the sutures, and the opposite peri-
toneal surface of the abdominal wall, are irritated with the point
of a scalpel in order to promote adhesions. Great care should
be observed that no loop of intestine finds its way between the

564
A TEXT-BOOK OF GYNECOLOGY.
uterus and the abdominal wall. In order to guard against this
the wire sutures should be kept taut by an assistant while the
abdomen is being closed; this is done in the usual way with silk
sutures. Sufficient tension upon the wire sutures is necessary
to keep the uterus in close contact with the abdominal wall. In
order to lessen the irritation of the skin surface it is my practice
to place strips of iodoform gauze beneath the wire sutures before
they are twisted. Finally, a retroversion pessary is introduced
into the vagina; this should be worn for some weeks for the
purpose of sustaining the uterus until the utero-abdominal adhe-
sions become firm. The patient is kept in bed for some time
FIG. 113.
GASTRO-HYSTERORRHAPHY. (Leopold.)
longer than is ordinarily necessary after abdominal section, so
that the newly-formed adhesions may not be prematurely
stretched. Drainage is unnecessary except in cases where
extensive adhesions have been separated.
Results and Prognosis of Gastro-hysterorrhaphy. It cannot
be said that this operation is as free from danger as is the
Alexander. Under modern antiseptic methods, however, the
mortality is very low. Nevertheless, the operation should be
reserved for those cases of retro-displacement which cannot be
overcome in the ordinary way, as, for instance, when the fundus
is bound down by adhesions or the ovary prolapsed. It is true
RETROVERSION AND RETROFLEXION.
565
that occasionally the cure is not permanent, but I am inclined to
believe that this is due to faulty operative technique. Experi-
ence thus far has proved that the operation does not interfere
with pregnancy, but it is yet too recent to speak dogmatically
regarding this point. When done for adhesions or for ovarian
prolapse, it is probable that much good would be accomplished
even were nothing more done than to overcome the adhesions
or remove the offending ovary. Whenever abdominal section is
made for other purposes, and the uterus is found retrodisplaced, it
should be fixed to the anterior abdominal wall before the abdomen
is closed. Strangely enough micturition is not interfered with.
Wylie of New York shortens the round ligaments within
the abdomen for the purpose of overcoming retrodisplacements.
He folds these structures upon themselves and at their middle
portion, some distance from the uterus, sutures them, first
scraping the peritoneum between the folded surfaces. Bode
of Dresden transfixes the round ligaments near the internal
abdominal ring with a needle threaded with aseptic silk.
He then passes the needle through the corresponding uterine
cornua at the insertion of the ligaments. After the two
ligatures are tied the ligaments are shortened to an extent
corresponding to the distance between the two knots. Polk
brings the round ligaments together in the form of an X above
the bladder, securing them in this position with sutures. All of
these operations overcome the displacements by shortening the
round ligaments, as does the Alexander. My unsatisfactory
experience with the Alexander, and the peculiar tendency of
the round ligaments to stretch, has led me to practise gastro-
hysterorrhaphy in preference.
Kaltenbach, Howard A. Kelley, Roux, and others have
practised to a greater or less extent abdominal hysterorrhaphy
without laparotomy. This seems to me infinitely more danger-
ous than laparotomy for the same purpose. By it there is great
danger of injuring the intestines, as an example furnished by
Roux emphatically demonstrates. This operator, feeling some
misgivings at the moment of passing the needle, opened the
abdomen and found that a loop of intestine would have been
penetrated had he persisted.
566
A TEXT-BOOK OF GYNECOLOGY.
Gastro-hysterorrhaphy: Illustrative Cases.
CASE LXIX.-Retroversion of the Uterus with Procidentia of the Second Degree.
Perineorrhaphy and Gastro-hysterorrhaphy. Recovery.—Patient, æt. 36. Referred
to me by Dr. L. T. Van Horn of Rives Junction, Michigan. Married for fourteen
years. Has had two children. Uterine trouble dates back to the birth of first child.
She had an operation some years ago upon the cervix and perineum, but the newly
made perineum is of a most superficial character and is absolutely useless, although its
antero-posterior diameter measures at least two inches. There is constant soreness in
the back with a great deal of pain in the left ovarian region. She describes this pain
as being of a pressing sensation, as though there were a ball pressing against the
pelvis. The menses are quite regular, but exceedingly painful. She also suffers
greatly from headache.
Physical Examination.—The os rests upon the perineum, the uterus is retroflexed,
and the left ovary is beneath the fundus.
The patient was placed upon the operating table November 11, 1892. The peri-
neum was first repaired by the author's method and a large retroversion Hodge
pessary placed in the vagina. The abdomen was then opened, the appendages
removed, and the fundus stitched with two wire sutures to the anterior abdominal
wall. No drainage was introduced. The abdominal walls were at least four inches
thick and some difficulty was experienced in passing the sutures. The patient con-
valesced nicely and returned to her home on December 24th. She is now (six months
after the operation) quite well.
CASE LXX.—Obstinate Retroflexion of the Uterus with Cystic Degeneration and
Prolapse of the Right Ovary. Gastro-hysterorrhaphy and Salpingo-oöphorectomy.
Recovery.-Patient, æt. 24. Referred to me by Dr. Walker of Salem, Michigan.
She has been almost entirely incapacited for the last three years because of a constant
distress and bearing-down sensation in the pelvic region, which completely unnerves
her. I found upon digital examination retroflexion of the uterus, with prolapse of
the right ovary, which was evidently greatly enlarged. The patient was placed under
palliative treatment for three months, but in spite of every effort I could not keep the
ovary out of the cul-de-sac, where it was constantly squeezed and irritated. She very
willingly consented, as a final resort, to abdominal section.
On February 1, 1892, the abdomen was opened and the right ovary, which was
four or five times its normal size, removed. The fundus was stitched to the anterior
abdominal wall in the usual way. The left ovary was not enlarged, though it was
attached to the floor of the pelvis by adhesions. These were broken up and the
appendages of the left side left intact. This was done at the urgent request of the
patient, who was about to be married and desired very much to have children. The
abdomen was closed without drainage.
The temperature reached 101° on the morning of the second day, and there was
evidently a slight localized peritonitis; but under a saline cathartic and bryonia this
quickly subsided, and the convalescence was rapid and complete. She has returned
to her business, and is now doing with perfect ease the work of a milliner.
CASE LXXI.—Intractable Dysmenorrhea following Ovariotomy for the Removal
of a Large Ovarian Cyst. Retroflexion. Oöphorectomy and Gastro-hysterorrhaphy.
Recovery.-Patient, æt. 38. Referred to me by Dr. S. S. Moffatt of Washington, D. C.
RETROVERSION AND RETROFLEXION.
567
Married; sterile. Has been a victim of dysmenorrhea from girlhood. Four years
previously to consulting me she underwent an operation for the removal of a large
ovarian cyst. She did not convalesce well, and there was left behind a distressing her-
nia of the abdominal wound. The dysmenorrhea became more marked after the
removal of the cyst.
Dr. Moffatt had exhausted all ordinary measures to overcome the dysmenorrhea. I
therefore reopened the abdomen in January, 1891, removed the appendages of the
opposite side, and stitched the uterus to the anterior abdominal wall. The scar-
tissue of the old wound was entirely removed and, owing to the thickness of the
abdominal walls, wire tension sutures were introduced. The wound was then closed
with silk sutures. The patient was exceedingly nervous and her mental condition
closely bordered on insanity. She made a somewhat tedious convalescence, but
finally recovered. There have been no signs of menstruation since the operation and
the uterus remains permanently fixed in front.

CHAPTER XXXVII.
DISPLACEMENTS OF THE UTERUS.-(Continued.)
Lateral displacements of the uterus are frequently associated
with the forms studied in the preceding chapter, and, when
slight, are of no consequence. As has been shown a slight
lateral version, because of the position of the rectum, is physio-
logical. Pathologically it results, in nearly all instances, from
FIG. 114.
C. 60ULLNAZ
UTERO-VAGINAL PROLAPSE.
inflammation of one or the other broad ligament, or from tumors
within the pelvis. The treatment, therefore, should be directed
to the condition giving rise to the displacement.
PROLAPSE OF THE UTERUS.
It is customary to speak of three degrees of prolapse or descent
of the uterus. In the first degree the organ is somewhat lower
in the pelvis than normal, though its axis corresponds to the
plane of the inlet.
568

PROLAPSE OF THE UTERUS.
569
In the second degree the cervix reaches the ostium vaginæ
and the axis of the uterus corresponds to the pelvic mid-plane.
In the third degree the uterus is wholly or in part outside of
the vagina, and its axis corresponds to that of the pelvic outlet.
This is known as complete procidentia (Fig. 116).
FIG. 115.
e
COMPLETE PROLAPSE OF THE BLADDER, UTERUS, AND RECTUM.
(a) Left labium; (b) edge of left vaginal wall, which has been cut away to expose
(c) uterus, and (d) bladder; (e) anus, through which the rectum (f) protrudes
for over two inches. The ovaries and broad ligaments are stretched and brought
down to the level of the external labia, but are healthy in structure. The
greater part of the bladder has been carried downward beyond the labia
together with the inverted anterior wall of the vagina. The patient had been
thus diseased for many years. (Museum R. C. S. Photographed by the Author.)
Etiology.-Anything that tends to weaken or destroy any of
the natural uterine supports will predispose to prolapsus uteri.
Of the various causes, parturition is unquestionably the most
important. The imperfect involution of the organ leaves it
heavy and congested. The uterine ligaments likewise undergo

570
A TEXT-BOOK OF GYNECOLOGY.
imperfect involution and are, consequently, easily stretched.
Added to these there is frequent relaxation and injury to the
pelvic floor which weakens the support from below. If, in this
condition, muscular exercise is excessive, the organ is crowded
more and more toward the pelvic outlet until finally it makes its
appearance externally. The rectum and bladder may be pro-
lapsed with the uterus (Fig. 115).
FIG. 116.
e
COMPLETE PROCIDENTIA OF THE UTERUS, VAGINA, AND BLADDER. (Wood.)
(P) pubes; (c) cervix; (e) enterocele. The cul-de-sac of Douglas is filled with
intestine. From a patient aged 67.
The usual form of complete procidentia is shown in Fig. 116,
the case from which the illustration was taken coming under my
own observation.
General feebleness of tissue and senility also tend to produce
procidentia. The displacement is much more common in elderly
women. It is often secondary to vaginal prolapse.
PROLAPSE OF THE UTERUS.
571
Pathology. Structural changes are usually associated with
the prolapsed organ. The cervical mucous membrane is
everted and erosions from friction are of frequent occurrence.
Endometritis with metritis and hypertrophy exist in nearly all
instances. The vagina becomes markedly hypertrophied in
complete procidentia and its cavity may be entirely lost by the
eversion. Its rugæ are destroyed, and from long exposure to
friction its epithelial layer becomes so thickened as to resemble
true skin. There is, even in descensus of the first and second
degrees, more or less prolapse of the anterior and posterior vagi-
nal walls with resulting cystocele and rectocele. The uterine
appendages are necessarily carried downward with the uterus
and, not infrequently, are inflamed.
Symptoms. These will depend upon the degree of the pro-
lapse and upon the complicating factors. The most frequent sub-
jective symptom is a bearing-down sensation. If the uterus pre-
sents externally the patient will herself suspect the cause of the
trouble. Difficult or painful micturition is an early and often a
prominent symptom, though, strangely enough, in some cases of
complete procidentia micturition is not especially difficult. There
is likewise more or less rectal irritation. The descent is increased
upon assuming the erect posture, and if the procidentia is of the
first or of the second degree it is relieved by lying down. Men-
strual disturbances are not necessarily very great. Locomotion
is interfered with and the general distress is aggravated by mus-
cular exertion, especially lifting.
Should the displacement occur suddenly, as a result of severe
muscular exertion or a fall, which is rarely the case, the symptoms
of shock and pressure may be most marked.
The physical signs are pronounced. Upon vaginal examina-
tion the uterus will be found either low down in the vagina or com-
pletely protruding from it. The degree of prolapse can best be
determined by completing the examination in the erect posture.
The uterus is usually increased in length. Prolapsus uteri will
have to be differentiated from-
Inversion and polypus;
Rectocele;
Cystocele ;
Hypertrophic elongation of the cervix.
572
A TEXT-BOOK OF GYNECOLOGY.
Inversion and Polypus.-In inversion of the uterus the os can-
not be found, and the bimanual will show the absence of the
fundus above. In polypi the uterus will be found above and
unless adhesions exist can be penetrated with the sound.*
Rectocele.-As we have seen, this is nearly always associated
with uterine prolapse. A degree of rectocele sufficiently marked
to simulate complete procidentia is of exceedingly rare occur-
rence. The uterus will be found above the rectocele. The
tumor can be penetrated per rectum, either with the finger or the
sound.
Cystocele.-A sound introduced into the bladder will penetrate
the tumor. The uterus is found above.
Hypertrophic Elongation of the Cervix.-The uterine cavity is
greatly increased in length and the bimanual will show the
fundus in its normal position. Prolapsus may be associated with
this condition (Fig. 117).
Prognosis. This will depend upon the degree of prolapse,
the age of the patient, and the existing complications. Usually
the condition becomes more and more aggravated as time goes
on unless operative interference is resorted to. Prolapse of the
first or of the second degree may be overcome by properly
fitted pessaries. When, however, procidentia becomes complete
a cure is rarely accomplished by palliative measures, although the
patient may be made more comfortable by them. In nearly all
cases, except when the patient is very old and complete proci-
dentia has existed for a long time, a cure is possible by proper
surgical interference.
Treatment.-An effort should first be made to remove the
cause or causes of the displacement. The treatment, therefore,
should be directed to chronic metritis or endometritis, if these
affections exist; or to the reparation of existing tears of the cer-
vix or injuries to the pelvic floor. All clothing should be
suspended from the shoulders in order to reduce intra-abdominal
* I once removed a soft myomatous tumor springing from the cervix which pro-
jected into the vagina and which was as large as a fetal head (Medical Counselor,
Vol. xi, p. 116). Adhesions had obliterated the cervical canal and at the most convex
portion of the tumor there was an opening corresponding very closely to the external
os. After breaking down the adhesions under ether, the sound passed into the uterine
cavity for nearly five inches, so that the diagnosis was made certain. The confusion,
however, was very great.

PROLAPSE OF THE UTERUS.
573
If the abdomen is pendulous the
pressure to its minimum.
patient should wear an abdominal supporter. The bowels and
bladder should likewise receive attention. Excessive muscular
exertion is, of course, injurious. The genu-pectoral posture will
afford much relief, bringing rest to the uterine supports. When
the uterus can be gotten into the vagina, astringents, such as the
saturated solution of alum, or powdered tannin sprinkled upon
glycerin tampons, will do much good.
FIG. 117.
HYPERTROPHIC ELONGATION OF THE CERVIX WITH PROLAPSE.
A median vertical section of the pelvic organs of an adult female. The cervix
uteri is much hypertrophied and elongated. The vagina is prolapsed, being com-
pletely everted. In descending with the vagina the uterus has drawn down its
peritoneal investments. The walls of the bladder are thickened. (Museum
R. C. S. Photographed by the Author.)
Some difficulty may be experienced in replacing the uterus in
complete procidentia. Before attempting to do so the rectum and
bladder should be emptied. If necessary the patient can be
placed in the genu-pectoral posture, when pressure upon the
cervix is made and the prolapsed uterus pushed upward. Too
574
A TEXT-BOOK OF GYNECOLOGY.
much force should not be exerted, especially in elderly women,
as there is danger of producing sloughing. In many in-
stances the reduction requires fifteen or twenty minutes for its
completion.
After the uterus is reduced an attempt should be made to
sustain it in its normal position by a pessary. Slight cases of
procidentia are frequently associated with more or less retrodis-
placement and may be corrected by a Hodge pessary, or one of
FIG. 118.
FIG. 119.


GTIEMANN'
CO.
INFLATED SOFT RUBBER
PESSARY.
G. TIEMANN & CO.
INFLATED BALL PESSARY.
FIG. 120.

GTIEMANN
THOMAS'S CUTTER'S CUP PESSARY FOR PROLAPSE.
its modifications. If the rectocele and cystocele are at all
marked, Greenhalgh's pessary with transverse bars is preferable
to the ordinary form. When this instrument cannot be retained
relief may be afforded by an inflated soft rubber pessary (Figs.
118 and 119). These act by distending the vagina; hence as
time goes on a larger instrument will be required. Any pessary
which sustains the parts by simply distending the vagina is
objectionable. Nevertheless, every now and then cases will be
PROLAPSE OF THE UTERUS.
575
met with where operative interference is impracticable, when
much relief will be experienced from the use of instruments of
this kind. When the sustaining power of the pelvic floor is en-
tirely destroyed some form of vaginal stem pessary is ordinarily
preferable to elastic or air pessaries. Of these Thomas's modifica-
tion of Cutter's cup pessary (Fig. 120) is one of the best. The
Mackintosh uterine supporters have also been much used for
this purpose. Any form of vaginal stem pessary should be
removed at night while the patient is in the recumbent posture,
and she should be instructed how to reintroduce the instrument
upon arising.
In all instances where the patient cannot tolerate a pessary
much relief will be experienced by sustaining the parts by
properly applied tampons medicated with some astringent solu-
tion or with powdered tannin.
Operative Interference.-The various operations for uterine
prolapse have for their object the restoration of the pelvic floor
and perineum and the narrowing of the vagina by anterior and
posterior colporrhaphy. After these operations are done it may
be necessary to fix the uterus from above to the anterior abdom-
inal wall. These various operations are described in Chapter
LII. Episeiorrhaphy, or closing the vulvar outlet, is now rarely
resorted to for procidentia. In most instances where entire
reliance is placed upon it for the purpose of keeping the uterus
within the vagina, prolapse again takes place.
Hysterectomy, except in cases where the uterus cannot be
returned to the vagina, is hardly a justifiable procedure. The
operation does not overcome the enterocele, and after the uterus
is removed intra-abdominal pressure will force the intestines
and vagina from the ostium. In most cases where reposition of
the uterus is impossible the patient is so far advanced in years,
and the prolapse has existed for so long a time, as to make
hysterectomy unadvisable. The comfort of the patient is not
greatly augmented by the operation.
Gastro-hysterorrhaphy, supplemented if necessary by an opera-
tion on the perineum, vagina, and cervix, may be done as a
final resort. It is especially indicated if the prolapse is compli-
cated with abdominal tumors which in themselves justify

576
A TEXT-BOOK OF GYNECOLOGY.
laparotomy. Le Fort has devised an ingenious operation for
keeping the uterus within the vagina. It consists in removing
a vertical strip of mucous membrane of varying width from
opposite vaginal walls and stitching the vivified surfaces
together.
INVERSION OF THE UTERUS.
The term "inversion" is applied to invagination of the uterus
on itself in such a way that the organ is turned inside out.
The accident may occur suddenly, as after parturition, or it may
be produced gradually, the result of some intra-uterine growth.
A very large per cent. of the cases
reported are directly traceable to
labor and the puerperal state.
FIG. 121.
THE SEVERAL DEGREES OF IN-
TRA-UTERINE INVERSION RE-
PRESENTED SCHEMATICALLY.
U, uterus; V, vagina. (Auvard
and Devy.)
Fig. 121 shows, schematically, the
several stages of intra-uterine inver-
sion, which may remain partial or be-
come complete. If complete, the in-
verted fundus projects into the vagina,
and often externally. The organ may
become hard or remain soft and vascu-
lar. If the cervical canal constricts the
parts, congestion is usually marked
and the constriction may give rise to
gangrene and sloughing. The Fallo-
pian tubes are drawn within the in-
verted cup and are more or less con-
stricted by the upper peritoneal ring.
Adhesions rarely form between the
opposing peritoneal surfaces.
If the uterus is not prolapsed the
position of the bladder remains un-
altered in its position; should there
be prolapse, a cystocele is formed.
Etiology.-Inversion of the uterus may occur in any one of
the following ways:-
1. The fundus is drawn down by improper traction upon the
cord during parturition.

INVERSION OF THE UTERUS.
577
2. Prolapse of some part of the fundus is caused by degener-
ation of the walls of the uterus. This is made worse by uterine
contractions and by pressure from above. The form of degen-
eration varies. Scanzoni believes it to be in most instances fatty.
According to A. R. Simpson, sarcomatous degeneration is the
most frequent form responsible for the accident.
FIG. 122.
AN UNIMPREGNATED INVERTED UTERUS WITH THE VAGINA, OVARIES, AND
OTHER PARTS.
Bristles are placed in the uterine orifices of the Fallopian tubes, which by the inver-
sion of the uterus have come to open obliquely into the upper part of the vagina.
Below is a polypus which was attached to the fundus of the uterus at the rough
spot now seen on the side of the Fallopian tube. A ligature was applied near
this attachment and it sloughed off just before the patient died. (Museum
R. C. S. Photographed by the Author.)
3. A polypoidal tumor, either malignant or non-malignant,
excites uterine contraction. The contractions force the tumor
downward, which drags a portion of the fundus with it. The
37

578
A TEXT-BOOK OF GYNECOLOGY.
inversion may remain partial, the fundus not escaping from the
os externum; or it may completely dilate the cervical canal and
pass into the vagina (Fig. 122).
4. Inversion from below upward may take place. Here there
is first eversion of the cervix, when the lower part of the uterine
body first passes into the cervical canal. This is the passive in-
version of Matthews Duncan, and is produced by uterine inertia
and not by uterine contractions.
It will thus be seen that the factors tending to produce inver-
FIG. 123.
INVERSION OF THE THIRD DEGREE. (Auvard and Devy.)
sion are those which alter the consistence and structure of the
uterine tissues. During parturition the organ is, of course, greatly
enlarged and the cervix dilated, so that it is a very easy matter
to drag the fundus downward by improper management of the
third stage of labor. General debility and wasting diseases also
act as predisposing causes. Severe muscular exercise and pres-
sure from above may force the fundus into the uterine cavity.
Symptoms. If the inversion occurs suddenly during partu-
rition the patient will complain of a feeling as though something
INVERSION OF THE UTERUS.
579
had given way, followed by a bearing-down sensation in the
pelvis. The hemorrhage is usually severe. The large mass
within the vagina interferes with micturition. Shock and even
fatal collapse may result from the accident. If the condition is
not corrected and the patient's life is spared, the symptoms of
chronic inversion present themselves. These are variable.
Usually hemorrhage either in the form of menorrhagia or met-
rorrhagia is the most prominent symptom; associated with the
hemorrhage are pelvic pain and distress, difficult micturition and
defecation, backache, painful locomotion, and the constitutional
symptoms due to the unnatural loss of blood. Leucorrhea is
also a prominent symptom.
Physical Signs.—When acute the large vascular fundus will
be found in the vagina, while the hand externally will fail to
locate, in its usual place, the hard contracted uterus. In its stead
there will be found a truncated body low down in the pelvis.
In chronic cases there will be detected upon digital examina-
tion a polypoidal body within the vagina which can be traced to
the cervix. If the inversion is not complete, the fundus not having
escaped into the vagina, intra-uterine exploration will locate it
within the uterus. In the event of complete eversion, the con-
tinuity of the tumor with the inner surface of the cervix will be
noted. The uterine canal is much shortened and the sound
will not penetrate it for more than an inch or an inch and a half.
Occasionally adhesions form between the cervical canal and
the fundus, so that the latter cannot be penetrated by the
sound.
The bimanual is next practised. The fundus is not found in
its normal position and, if the abdominal walls are not too thick,
the characteristic depression can be detected. If the conditions
are unfavorable for successful bimanual the absence of the fun-
dus in its normal position may be determined by drawing the
tumor within the vagina downward and examining per rectum.
A sound now passed into the bladder will come in contact with
the finger in the rectum, showing the absence of the uterus be-
tween the two.
By careful examination of the tumor it is usually possible
to locate the opening of the Fallopian tubes.
580
A TEXT-BOOK OF GYNECOLOGY.
The condition will have to be differentiated from prolapsus
uteri and from hypertrophic elongation of the cervix (v. p 571).
Termination.-A spontaneous cure of the inversion is of
rare occurrence. Unless corrected the hemorrhage and dis-
charge, together with the friction resulting from the unnatural
location of the fundus within the vagina or externally, greatly
prostrate the patient. There is constant danger of strangulation
with consequent septicemia.
Treatment.—An effort should be made to reinvert the uterus
as soon as the accident is discovered. Immediately after de-
livery this is not usually difficult. The placenta should be com-
pletely detached and the fundus boldly pushed upward with one
hand, while pressure is exerted from above with the other. The
hand should remain in the uterine cavity until the uterus con-
tracts firmly down upon it.
In cases of long standing the treatment is much more difficult,
although Audige records a case of thirty years' duration in
which a cure was accomplished.
An effort may be made to restore the fundus to its normal
position by-
Manual reduction;
Reduction by gradual compression;
Taxis with instruments.
Too much persistence should not be practised. Failing with
these measures, especially in chronic cases, we are then justified
in resorting either to amputation or to vaginal hysterectomy.
Manual Reduction.-After anesthesia the fundus is grasped
with three fingers of one hand, while the other hand steadies the
uterus through the abdominal wall. An attempt may be made
either to reinvert the fundus en masse, or to reduce it gradually
by inverting first one cornu and then the other. Courty makes,
if necessary, several longitudinal incisions through the circular
fibers of the cervix in order to overcome the contraction. He
then exerts counter pressure upon the truncated end of the
uterus with two fingers in the rectum, while the attempt is being
made to reinvert the fundus. After the fundus is pushed into the
uterine cavity Emmet advises closure of the cervix with sutures
if the reduction is not complete.
INVERSION OF THE UTERUS.
581
Reduction by Gradual Compression.—The patient is prepared
by hot vaginal douches and rest in bed, in order to reduce con-
gestion as much as possible. This preparation is also important
before manual reduction is attempted. Gradual pressure may
be exerted by an air pessary (Fig. 118), by a cup stem pessary
fixed on an abdominal belt, by a colpeurynter, or by tamponne-
ment with iodoform gauze. Pozzi prefers the latter method.
He packs with some force long strips of gauze around and above
the tumor. These are removed every two or three days. The
Fig.2.
FIG. 124.

Fig.1.
b
g
G.TIEMANN & CO
C
WHITE'S UTERINE REPOSITOR.
patient is kept in a horizontal position during the treatment.
Evacuation of the bowels and bladder should be carefully looked
after. Pozzi maintains that this treatment will accomplish all
that can be done by other methods of gradual compression, and
that it possesses the advantages of being simple and requiring
no special instrument.
Taxis with Instruments.—Special repositors have been de-
vised for the purpose of exerting taxis. Fig. 124 represents
White's repositor. It consists of a staff with a soft rubber cup
attached to one extremity, which fits over the fundus, and a spiral
582
A TEXT-BOOK OF GYNECOLOGY.
spring attached to the other, which is applied against the chest
of the operator. This instrument is useful, but long-continued
pressure by it is liable to produce sloughing. Thomas's method
of opening the abdomen and dilating the cervical ring with an
instrument similar to a glove-stretcher is no longer recommended.
J. M. Baldy* of Philadelphia says that he has seen the abdomen
opened, the cervix dilated with dilators, and traction exerted
from above with a stout cord passed through the fundus into the
vagina without avail. He, therefore, considers all of these
methods distinctly illogical and dangerous, and believes they
should be set aside in favor of the safer method of vaginal
hysterectomy after a reasonable attempt has been made to over-
come the inversion with the vaginal tampon.
Of the radical operations, the inverted fundus may be ampu-
tated, or the entire uterus removed by vaginal hysterectomy.
The choice between amputation and hysterectomy will depend
upon circumstances. As a general rule I think vaginal hysterec-
tomy, as now practised, is the preferable operation. If the fundus
is in the way, the cervix can first be secured in an elastic ligature,
by which means hemorrhage is controlled, and the tissue below
cut away. This step will enable the operator to remove the
cervix and secure the broad ligaments with but little difficulty.
If simple amputation be resorted to, care must be observed
not to permit the stump to retract into the abdominal cavity.
An elastic ligature is thrown about the neck of the tumor, below
which two or three wire sutures are made to transfix the cervix
antero-posteriorly. The uterus is then removed half an inch
below the sutures and the bleeding points of the stump secured
with catgut. The edges of the wound are next approximated
with the wire sutures previously passed. These are left long
enough to project from the vagina, so as to prevent retraction
of the stump. Superficial sutures may be placed between the
deeper ones if necessary to insure perfect coaptation of the
mucous membrane covering the stump. The elastic ligature is
removed after the wire sutures are secured. This method is
preferable to amputation or by the écraseur.
* Medical and Surgical Reporter, July 25, 1891.
CHAPTER XXXVIII.
FIBROID TUMORS OF THE uterus.
Definition.-Fibroid tumors of the uterus result from localized
hypertrophy due to increased nutritive activity of the uterine
muscular and connective tissue. They are composed of both con-
nective tissue and muscular elements, and are, therefore, both
fibromatous and myomatous in character. The fibrous and
muscular tissue rarely exist in equal proportions, the one or
the other preponderating. In by far the larger number of
cases the fibrous tissue is in excess, and the term uterine fibroid,
most commonly applied to these new formations, is, therefore,
not inappropriate.
Pathology. When first formed, they consist largely of
muscular fibers of the non-striped variety, and are simply
outgrowths from preëxisting muscle tissue. Embedded in the
stroma of non-striped muscle tissue are glands lined with ciliated
columnar epithelium similar to that found in the uterine glands.
As time goes on these growths usually undergo fibrous trans-
formation, the fibrous tissue developing at the expense of the
muscular, although rarely, if ever, supplanting it entirely. When
the muscular tissue preponderates they are usually very vascular
and contain large sinuses. After undergoing fibrous changes,
the vessels are surrounded by a mass of fibrous tissue, which
has a tendency to obliterate them (Gibbes).
Varieties. In the beginning all fibroid tumors are located in
the walls of the uterus, and are, therefore, interstitial or intra-
mural (Fig. 125). As time goes on they grow either toward the
peritoneal cavity, becoming subserous, or toward the uterine
cavity, becoming submucous. Hence, clinically, three varieties
are distinguished-interstitial, subserous, and submucous. The
tumor may remain indefinitely in the walls of the uterus, assum-
ing large dimensions. Should it approach either the serous
covering of the uterus or its mucous lining, the surrounding
583

584
A TEXT-BOOK OF GYNECOLOGY.
parenchyma will be excited by its presence and the resulting
contractions will force it still farther toward the abdominal or
the uterine cavity. As time goes on the broad base is often
converted into a slender pedicle, producing the so-called pedun-
culated subserous, or the pedunculated submucous fibroid,
FIG. 125.
B
لة
Peritoine
B
4
Péritoine
A
Muqueuse
Muqueuse
C'
DIAGRAM SHOWING THE BEGINNING OF FIBROMA UTERI AND THEIR MODE OF
GROWTH. (Auvard and Devy.)
A. Interstitial fibroid, which remains interstitial (1, 2, 3, 4). B. Fibroid, which was
at the beginning interstitial, but which has developed in the direction of the perito-
neum, becoming gradually transformed into a pedunculated sub-peritoneal tumor,
B', C. Fibroid, which was at the beginning interstitial, but which has developed in
the direction of the uterine cavity, becoming gradually transformed into a sub-
mucous polypus, C'.
as the case may be. The last-named condition constitutes a
fibrous polypus.
Number, Size, and Location.-The number of uterine fibroids
varies greatly-from one to fifty. Thomas records a case where
the uterus, removed from a negress, contained thirty-five tumors,

FIBROID TUMORS OF THE UTERUS.
585
varying in size from that of a marble to a fetal head. They are
oftener located in the body of the uterus, but may develop
in any part of the organ. The posterior wall of the fundus is
the most frequent location; the rarest of all is the cervix. In
FIG. 126.
4637
The tumor
(Museum R. C. S.
A uterus in the walls of which are eight or nine large fibrous tumors.
cut open is imbedded in the posterior wall of the womb.
Photographed by the Author.)
size they range from that of a walnut to tumors weighing seventy-
five pounds.
Structure. As already intimated, the proportion of the mus-

586
A TEXT-BOOK OF GYNECOLOGY.
cular and fibrous tissue varies greatly. When the former pre-
ponderates, the tumor is soft, vascular, and grows rapidly. The
muscular fibers blend insensibly with those of the uterus.
Upon section, the tumor is of a pale flesh color. If the fibrous
element is in excess, the consistence is firm and cuts like cartilage.
Fibroid tumors are enclosed in a layer of loose fibrous tissue
surrounded by a muscular layer; this is the so-called capsule.
FIG. 127.
4639
A uterus, enlarged by pregnancy, attached to the right side of which is a perfectly
solid fibro-myomatous tumor, ten inches in its vertical diameter. It is attached
to the uterus by a thin band of connective tissue four inches in length. (Museum
R. C. S. Photographed by the Author.)
But few blood-vessels penetrate their substance, although the
capsule and contiguous structures often contain large venous
sinuses, which supply nutrition to the growth by transudation.
Occasionally, as has been shown, they possess a cavernous struc-
ture of dilated blood-vessels (Hart and Barbour.)
Microscopically they consist of non-striped muscular fibers
embedded in a fibrous stroma. The fibrous tissue
The fibrous tissue may be sepa-
FIBROID TUMORS OF THE UTERUS.
587
rated by lymphatic tissue (Klebs). Lorey has traced nerve
fibers into the substance of fibroid tumors, although the sub-
stance itself is not sensitive. Sub-mucous fibroids are sensitive
while the capsule is yet intact, because of the nerve supply of
the mucous membrane (Freund).
Mode of Growth.—Subperitoneal tumors grow toward the peri-
toneal cavity. They may be either pedunculated or sessile,
the size of the pedicle varying greatly in different cases. As
they extend toward the peritoneal cavity they drag the uterus
with them, and often greatly distort this organ. The traction
induced in this way has been known to separate the body of the
uterus from the cervix (Virchow). Should a tumor not find its
way into the peritoneal cavity but remain in the pelvis, incar-
ceration may occur. Occasionally the pedicle becomes twisted,
as in ovarian tumors; the result of this is edema and gangrene
which may end in fatal peritonitis. Should the pedicle become
completely separated, the nutrition may be maintained by the
growth attaching itself to surrounding structures.
Interstitial tumors are rarely single, and many times cause an
enormous increase in the dimensions of the uterine walls.
Submucous tumors are first attached by a broad base. Sooner
or later pedunculation is produced by uterine contractions,
though the size of the pedicle is most variable. They constitute
the most frequent form of uterine polypi. The presence of these
tumors acts as a foreign body and gives rise to uterine contrac-
tions. There is, therefore, a natural tendency for the uterus to
extrude them and force them into the vagina. Should the
capsule rupture they may be expelled piecemeal or en masse, a
process known as spontaneous enucleation (Hart).
Degenerative Changes.-These are :—
Suppuration;
Softening;
Induration;
Calcification;
Malignant degeneration.
Suppuration.—Suppuration may follow or accompany any of
the other degenerative changes mentioned.
It occurs much
oftener in submucous than in the other two varieties. Occa-

588
A TEXT-BOOK OF GYNECOLOGY.
The most
sionally it is met with in subperitoneal tumors.
frequent cause of suppuration is interference with the circula-
tion, resulting from uterine contractions. It may also be due to
operative interference (Hart and Barbour).
FIG. 128.
4638
A uterus with two large fibrous tumors, which were situated between it and the
rectum. They had probably grown just beneath the peritoneum of the posterior
wall of the uterus and are situated one above the other. The patient was 91
years old and carried the tumor for thirty-seven years. (Museum R. C. S.
Photographed by the Author.)
Softening. This results from fatty or myxomatous degenera-
tion. Gusserow has found fatty degeneration in fibroid tumors.
Myxomatous degeneration gives rise to spaces between the
layers of the tumor, which become distended with mucus. This

FIBROID TUMORS OF THE UTERUS.
589
is probably the beginning of so-called fibro-cystic tumors of
the uterus. Edema is oftener due to twisting of the pedicle;
when it occurs there is either a gradual or a rapid increase in
the size of the tumor.
Induration.-This change is connected with the menopause.
It is probable that the atrophy and shrinking are due to the
absorption of the muscular tissue with subsequent contraction
of the fibrous (J. N. Simpson).
FIG. 129.
4636
A uterus with the Fallopian tubes, ovaries, etc. A fibrous tumor of the shape and
size of an ovary is attached by a broad band of peritoneum to the angle of the
fundus of the uterus, near the right Fallopian tube. There are no interstitial
tumors. (Museum R. C. S. Photographed by the Author.)
Calcification. This results from a deposition of lime salts
and is a species of calcareous infiltration. The growth is per-
meated with phosphate and carbonate of lime. I have in my
possession a tumor removed post-mortem which has completely
undergone this change. The entire uterus is stone-like in hard-
ness, and the sawed surface has the appearance of a calcareous
mass. The process is similar to the transformation of pulmonary
tubercles which undergo cretaceous degeneration. The resulting
590
A TEXT-BOOK OF GYNECOLOGY.
changes impair the nutrition of the tumor, and the mass-the
so-called womb stone of the older authors-may be expelled per
vaginam. Not infrequently suppuration is associated with calcifi-
cation.
Malignant Degeneration.—I think that there is no doubt that
fibroid tumors may undergo malignant degeneration. Such at
least is the testimony of the majority of modern pathologists
and gynecologists. A case is recorded by A. R. Simpson where
the body of the tumor when cut into presented all the charac-
teristics of a true fibroid. Several islands of sarcomatous
degeneration were located in the midst of the fibrous tissue.
In nearly all modern text-books can be found instances of
similar cases. I had under observation for three years a case
of fibroma of ten years' duration. It suddenly increased in
size, and operative interference became imperative. An explo-
ratory incision revealed not only malignant degeneration of the
tumor, but of nearly all of the pelvic viscera. It is hardly
probable that the growth could have existed so long had it
been malignant from the onset.
Martin (Annals of Gynecology for February, 1889) records
six cases of fibroma uteri in which sarcomatous changes were
met with. In all instances the patients had been under treat-
ment by ergotine for a long time. This drug succeeded in
every case in controlling the abnormal hemorrhages and in
apparently reducing the volume of the growths. This same
author also notes nine cases of myoma associated with car-
cinoma. In some of the cases the carcinomatous disease had
invaded the cavity of the uterus without extending to the
tumor. Martin is of the opinion that myomas are never de-
stroyed by carcinoma, though the two diseases may exist
together. Cushing* has also recorded an instance of fibro-sar-
coma of the uterus. Coe † and Liebmann ‡ have both observed
uterine fibroids which have undergone cancerous degeneration,
a microscopical examination showing groups of round cells
invading the general fibrous structure.
* Medical Record, May, 1889.
† American Journal of Obstetrics, January, 1889.
Centralblatt für Gynekologie, November, 1889.

FIBROID TUMORS OF THE CERVIX.
FIBROID TUMORS OF THE UTERUS.
591
When fibroid tumors are located in the cervix, they may
spring from either wall and grow downward into the cellular
tissue beside the vagina, or upward toward the peritoneal
cavity (Fig. 130). They greatly distort the cervix and the
pelvis, and, because of their low position, frequently become
incarcerated. Some difficulty in diagnosis may arise from the
danger of confounding them with inversion of the uterus (v.
p. 571). Fortunately, they are rarely located in this region.
FIG. 130.
CO.
FIBROID SPRINGING FROM POSTERIOR WALL OF CERVIX.
Etiology.-It is possible to study only the circumstances under
which fibroids appear, for, as to their exact cause, nothing certain
is known. That there is an exaggerated local nutrition is un-
questionable. But just why exaggerated local nutrition should
in one instance produce fibroma, in another myoma, and in still
another simple hyperplasia of the uterus, or simple hyper-
trophy, it is hard to determine. From the fact that they are
the most frequent new formations found in the uterus, it is
evident that the cause, whatever it may be, is operative in
many instances. It is estimated by Klob that fifty per cent.
592
A TEXT-BOOK OF GYNECOLOGY.
of the women who reach the age of fifty have fibroma uteri.
While this estimate is probably too high, there is no doubt, as is
clearly shown by dead-room examinations, that a goodly per
cent. of women of all ages have uterine fibroids, though in
many instances their presence is not suspected during life.
Under the head of predisposing causes it will be necessary to
note :-
Environment;
Race;
Age;
Celibacy;
Child-bearing;
Menstrual disorders;
Heredity.
Environment.-Schroeder found in his polyclinic that among
the poorer classes the proportion of carcinomas to myomas was as
100 to 61; in his private practice, which was largely among the
wealthier classes, it was as 100 to 332. These statistics, as far as
they go, show that fibroma is oftener met with in the higher
walks of life and carcinoma in the lower.
Race. It is said that the African race is particularly liable to
fibroid tumors.
Age.-The age of greatest sexual activity, 25 to 40, predis-
poses to fibroma uteri. The larger number of cases occur be-
tween the ages of 30 and 40.* When met with after the meno-
pause, it is probable that in nearly all instances they have existed
for some years previously to the cessation of the flow.
Celibacy. The statistics of different authors are conflicting as
regards the influence exerted by celibacy upon the production of
fibroids. Emmet believes that celibacy predisposes to their for-
* Gusserow's statistics :-
Out of 919 cases 15 were below 20 years.
156" between 20 and 30 years.
357
338
30
40
40
50
36
12
50
" 60
60"
70
5
above 70 years.
(Hart and Barbour.)
FIBROID TUMORS OF THE UTERUS.
593
mation. On the other hand, of the 959 cases recorded by Gus-
serow, 672 were married women.
Child-bearing.-It has been observed that sterility frequently
precedes the appearance of uterine fibroids. It was therefore
supposed that the congestion incident to uninterrupted menstrua-
tion predisposes to their formation. The more probable ex-
planation is, that the tumor or tumors existed long before giving
rise to symptoms attracting attention to the uterus, and were,
therefore, the cause rather than the result of sterility.
Menstrual Disorders.-The various menstrual disorders at-
tended with congestion of the uterus and the pelvic organs pre-
dispose to the formation of fibroids by bringing to the uterus
exaggerated local nutrition. Here, as with sterility, it is difficult
to determine in a given case whether the dysmenorrhea, which
frequently precedes the detection of the tumor, is the cause or
the result of the growth.
Heredity. The statistics bearing upon this point are most
unsatisfactory. It is probable that in the past hereditary influ-
ences have been very much overestimated.
Symptoms. These vary greatly in different cases. They are
by no means dependent upon the size of the tumor; for a large
growth may exist for an indefinite length of time without creat-
ing the least distress, while a small one may cause the most
excruciating pain.
The symptoms can be advantageously studied under the fol-
lowing heads:-
Hemorrhage ;
Leucorrhea;
Dysmenorrhea;
Pain and pressure symptoms;
Sterility and abortion.
Hemorrhage. Hemorrhage occurs either in the form of
menorrhagia or metrorrhagia. It is much more profuse when
the tumor grows toward the uterine mucosa. The blood does
not proceed from the body of the tumor but from the en-
dometrium, which is hypertrophied and frequently undergoes
fungoid degeneration. It is probable, also, that there is more
or less interstitial metritis attending the growth of the tumor,
38
594
A TEXT-BOOK OF GYNECOLOGY.
which to a greater or less extent predisposes to hemorrhage.
The patient often becomes greatly exsanguinated from the loss
of blood, and even sudden death may be produced by it. In case
of fatal hemorrhage the blood proceeds from a ruptured uterine
sinus. The quantity of blood lost by no means depends upon
the size of the tumor. A small polypoidal mass projecting
into the uterine cavity will sometimes give rise to a most persist-
ent flow of blood; whereas a large interstitial or subserous
fibroid may not excite any hemorrhage whatever.
Leucorrhea. The leucorrheal discharge, when it exists, is due
to the same causes-endometritis and metritis-which produce
hemorrhage. It is of a serous nature and, unlike that resulting
from cancer, is odorless.
Dysmenorrhea.—Painful menstruation results both from the
mechanical pressure exerted by the tumor, and from the increased
congestion arising from its presence. It is usually more severe
in submucous growths, especially if pedunculation has begun.
The pain is labor-like in character, and is due to exaggerated
uterine contractions. In the interstitial and subserous varieties
it is probable that the suffering results from the distention of the
tumor with blood at this period (Gusserow).
Pain and Pressure Symptoms.-Pain frequently results during
the intermenstrual period, although it is usually aggravated by
the onset of the catamenia. In those instances where the tumor
is enclosed in a firm capsule and grows uniformly in all direc-
tions, it is due to the tension attending the growth of the tumor.
There is a sensation of increased weight and bearing down with
large tumors. Excessive pain is often excited by the pressure
of the tumor upon neighboring structures, and not infrequently
extends down one or both thighs. Pain from this cause may be
confined either to the anterior or the posterior surface of the limb,
depending upon the nerves involved. The veins passing to
the lower extremities may likewise be implicated sufficiently
to produce varicosis. Occasionally the ureters are obstructed,
though this accident occurs less frequently with fibroid tumors
than with carcinoma; nevertheless, the pressure may be great
enough to give rise to hydronephrosis. Dysuria from pressure
upon the bladder or urethra is not an infrequent symptom.
FIBROID TUMORS OF THE UTERUS.
595
If the tumor presses against the rectum, there will be constipa-
tion, or, occasionally, diarrhea. All of the pressure symptoms
are aggravated during menstruation. Should incarceration
occur, complete intestinal obstruction may ensue.
Sterility.—Sterility is present in about thirty-three per cent.
of all cases of fibroids occurring in married women. Should
conception take place, the presence of the fibroid will frequently
cause abortion.
Physical Signs.-Ordinarily the diagnosis is much more
easily made than is the case with ovarian tumors. Great dif-
ficulty may, however, sometimes arise, especially if inflammatory
symptoms are associated with the fibroma.
Small interstitial fibroids may escape detection. If the condi-
tions are favorable, the bimanual will reveal an undue thicken-
ing in some portion of the uterine wall. If in doubt, a sound
should be used with the bimanual, when the thickening of the wall
can be more readily detected. Should the tumor be located in
the posterior wall, the unusual thickness of tissue intervening
between the sound in the uterus and the finger in the rectum
will be recognized; the localized hardness can also be deter-
mined by the finger in the rectum.
If pedunculated submucous fibroids do not project from the os,
the cervical canal must be dilated. The finger can then be
introduced into the uterus and the diagnosis readily made.
Care must be taken not to confound this condition with inver-
sion of the uterus (v. p. 571).
The examiner will be called upon to distinguish small fibroids
from-
(a) Ante- and retroflexion.-In ante- and retroflexion the
tumor, which is felt through the posterior vaginal fornix, will
be penetrated by the sound. Unless the fundus is adhered, it
can be lifted out of its unnatural site and the presence or ab-
sence of a fibroid determined by practising the bimanual.
(b) Chronic Metritis.-In chronic metritis there is usually
more or less tenderness; the os is patulous and the uterus
symmetrical.
(c) Early Pregnancy.—If pregnancy is suspected the sound
must not be introduced. The ordinary symptoms of pregnancy
596
A TEXT-BOOK OF GYNECOLOGY.
are seldom wanting. The cervix is soft, and, indeed, the whole
uterus when gotten between the two hands is much softer than
it is in the case of fibroids. It is entirely possible for concep-
tion to occur when the uterus contains one or more small
fibroids.
In the diagnosis of large fibroids it will be necessary to
proceed systematically. The various conditions giving rise to
distention of the abdomen are fully discussed in Chapter XLV.
When the tumor passes into the general abdominal cavity
there will be dulness on percussion over an area corre-
sponding to its outlines, unless at a point where a loop of
intestine intervenes between it and the abdominal wall. The
growth is traced by palpation into the pelvis. There may be
detected upon auscultation a bruit or souffle, which is due to
the enlarged arteries and veins supplying the tumor. Upon
vaginal examination a mass, more or less intimately connected
with the uterus, will be found. It is continuous with it in inter-
stitial and submucous growths, whereas in subserous fibroids
with a long pedicle it is sometimes more difficult to determine
the attachment to the uterus. Ordinarily, however, the tumor
will move with the uterus when the latter is dragged down by
means of the volsella. The sound will determine the length,
direction, and distortion of the uterine canal. The length is
not greatly, if at all, increased in subserous tumors; in the
interstitial and submucous varieties the canal is usually not only
increased, but greatly distorted as well.
Large fibroid tumors may be confounded with-
(a) Ovarian Tumors.-The history of menorrhagia is less
marked and the uterus does not merge into the tumor, as is the
case with fibroids. The uterine cavity is seldom, if ever, in-
creased in size, and unless the tumor is attached to the fundus
by adhesions the uterus moves independently of it. An ovarian
cyst is more soft and elastic than is a fibroid.
(b) Advanced Pregnancy.-The usual signs of pregnancy
should be looked for: the uterus is of softer consistence; the fetal
movements and heart-beats can ordinarily be detected; there is
amenorrhea instead of menorrhagia.
(c) Hematocele and Inflammatory Deposits.—In the case of
FIBROID TUMORS OF THE UTERUS.
597
hematocele there will be a history of shock and collapse followed
by inflammatory symptoms. If the tumor is due to inflam-
matory deposits, the history of inflammation can be elicited.
Both inflammation and hematocele may complicate fibroid
tumors.
(d) Cancer of the Uterus.—The pain is usually greater than in
fibroid, the discharge more offensive, and the hemorrhage more
irregular. In cases of suppurating submucous fibroids it may be
necessary to resort to the microscope before an accurate diag-
nosis can be made.
Progress and Termination.-The clinical history of the
ordinary hard fibroma and the rapidly-growing edematous
myoma is usually very different. The former is hard, slow
growing, and usually comes to a standstill at the menopause; the
latter occurs at any age, the symptoms are more urgent, and it
is seemingly not affected by the menopause or by the removal
of the appendages (Tait).
Should pregnancy occur in a uterus the seat of fibroid, the
growth may increase in size with the development of the uterus.
Occasionally, pari passu with the process of evolution, retro-
grade metamorphosis, or even complete absorption, may take
place. It is supposed that this is brought about by a process
of fatty degeneration similar to that which the uterus under-
goes during the parturient period (v. p. 610).
Any of the forms of fibroids may delay the menopause in-
definitely. When menstruation finally ceases, and senile uterine
changes are established, the tumor ordinarily stops growing
because of the diminished vascularity of the pelvic organs.
Spontaneous cures sometimes result either by pedunculation
and extrusion of the tumor as a polypus, or by disintegration,
the fragments being expelled per vaginam. Spontaneous expul-
sion in this way can only occur in interstitial and submucous
tumors. It is brought about by the capsule giving way, usually
the result of ulceration, the uterine contraction expelling the
tumor either en masse or piecemeal.
Prognosis. Uterine fibroids, if uncomplicated, rarely cause
death. The prognosis is much more unfavorable when the mus-
cular element preponderates than in the hard variety of tumor.
598
A TEXT-BOOK OF GYNECOLOGY.
Death, when it results, may be due to hemorrhage, to uremia
from compression of the ureters, to septicemia from suppuration
and disintegration of the tumor, or to acute peritonitis. It be-
comes necessary, therefore, in determining the prognosis in a
given cease to note the variety of the tumor, its location in the
pelvis, the age of the patient (the nearer she has approached the
menopause the more favorable the prognosis), and the existing
symptoms, of which hemorrhage is the most important. Gener-
ally speaking, it may be said that, as regards life, the prognosis is
favorable. The presence of the tumor, nevertheless, frequently
gives rise to years of suffering and much anxiety.
CHAPTER XXXIX.
FIBROID TUMORS OF THE UTERUS.-(Continued.)
TREATMENT.
The treatment of fibroid tumors of the uterus resolves itself
into (a) palliative and (b) curative.
Palliative Treatment.-In by far the larger number of cases
nothing more than palliative treatment is called for. This should
be directed to the hemorrhage, to uterine displacements if they
exist, and to the pressure symptoms.
It is not always possible to control the hemorrhage even
though all ordinary resources are exhausted. For its immediate
control the recumbent posture, the internal remedy, the vaginal
tampon, and the hot douche may be brought into requisition.
The patient should, during the intermenstrual period, abstain
from any cause tending to produce pelvic congestion. Sexual
excess is for this reason pernicious. Constipation will likewise
give rise to congestion of all the pelvic organs. Attention
should also be paid to the functions of the liver and the skin.
The remedies useful in polypi of the uterus, and in menor-
rhagia and metrorrhagia from other causes, are the ones most
frequently indicated in the treatment of hemorrhage resulting
from uterine fibroids;* and the same principles of treatment
adopted for the relief of menorrhagia due to endometritis are
here applicable. I have more than once succeeded in control-
ling hemorrhage for a greater or less length of time by the
application of the sharp curette. This instrument is especially
indicated if the presence of the tumor or tumors delays the
menopause.
In using the vaginal tampon it should be applied in a most
thorough manner. The carbolized cotton may be soaked in a
saturated solution of alum. In most instances the excessive
*
7. pp. 252 and 624.
1
599
600
A TEXT-BOOK OF GYNECOLOGY.
loss of blood can be controlled in this way. The hot douche,
if its hemostatic properties are to be obtained, must be used in
large quantities, and at a temperature of not less than 115°.
A still more valuable palliative agent is electricity. I speak of
it as a palliative agent only, because I believe that fibroids are
rarely if ever entirely cured by its use. Electro-puncture, as
practised by Apostoli, Englemann, and others, I never use. It
seems to me infinitely more dangerous than laparotomy, but
galvanism applied in the usual way will frequently do much good.
The technique of its application is given in Chapter XI. It is
only necessary at this time to add that benefit will often follow
the use of the milder currents-80 to 100 milliamperes-con-
tinued for a period of from two to six months. If carefully and
intelligently localized within the uterus, a current of this strength
is not dangerous and the benefit is often most marked. As
a conservative measure, then, electricity, unless the case is an
urgent one, should be faithfully tried before radical surgical
treatment is decided upon.
Surgical Treatment.-In interstitial and submucous tumors
the hemorrhage may be controlled by incising the investing
coat, the incision extending into the superficial layer of fibers.
The practice inaugurated by Amussat, and popularized by
McClintock, Nélaton, and others, of making incisions at the
sides of the cervical canal is also recommended by certain
authors. In both of these instances the hemorrhage is prob-
ably relieved by diminishing the vascular supply of the uterus
and tumor.
Radical surgical treatment will vary according to the char-
acter, the location, and the size of the fibroid. If it projects
into the uterine cavity, and especially if pedunculation has
taken place, it is entirely practicable, unless unusually large,
to enucleate it through the vaginal and the cervical canals.
However, when it is necessary forcibly to dilate the os, incise
the capsule, and shell out the tumor; the operation is not only
exceedingly difficult but hazardous as well. I confess that I
undertake an operation of this kind with much more hesitancy
than I do an abdominal section for the removal either of the
entire uterus or its appendages. Nevertheless, when the tumor
ព
FIBROID TUMORS OF THE UTERUS.
601
E
Lad
makes its appearance at the external os, or is partially within the
vagina, especially if the capsule is already disintegrated, an
attempt should be made to enucleate and remove it per vaginam.
The danger here is much less than would be incurred by abdomi-
nal section.
The Operation of Enucleation.—The patient should be prepared
as for any capital operation. It is particularly important to have
the bowels and bladder emptied. She may be placed either in the
lithotomy or the Sims posture, as the operator may prefer. After
being anesthetized, the parts are exposed by the aid of suitable
specula and a careful exploration made. The surgeon should
determine as accurately as possible the relation of the tumor to
the interior of the uterus. Pressure from above by an assist-
ant will crowd the uterus to the outlet of the vagina and will
FIG. 131.
> G. TIEMANN & CO
GREENHALGH'S TUMOR FORCEPS.
€

greatly facilitate the operator's manipulations; it is even pos-
sible to depress the uterus so far that a speculum is unneces-
sary. The operator then grasps the cervix in a strong pair of
volsella and makes a deep incision through the capsule with the
point of a scalpel guarded by the finger. An effort is next
made to peel the capsule from the tumor, which process is
facilitated by grasping its edges with stout pressure forceps.
The finger should be used as much as possible for this purpose.
After the tumor is exposed it is seized with a pair of strong
volsella (Fig. 131). By traction upon the handles of the volsella
thus placed the tumor is drawn downward with a slight rotary
movement, while the forefinger continues to detach the capsule.
The various instruments devised for the purpose of aiding in
the process of enucleation are exceedingly dangerous, and most
602
A TEXT-BOOK OF GYNECOLOGY.
of the inventors have discarded their use. Thomas and Mundé
state that they now use Thomas's well-known spoon saw much
less frequently than formerly. The great danger attending
the use of all such instruments is the liability of perforating the
walls of the uterus. If the finger cannot reach far enough to
complete the dissection, a strong steel male sound may be
resorted to. By sweeping this over and around the tumor the
deep lines of adhesion can be separated.
If the tumor is very large it may be necessary to incise it by
means of a scalpel or scissors before it can be delivered. Care
must be observed, as the enucleation is about to be completed, not
to invert the uterus by excessive traction. Should this accident
occur, the attachments of the tumor should be cut away,
the parts
washed with an antiseptic solution, and the fundus returned to
its normal position. It is sometimes exceedingly difficult to
distinguish an inverted uterus from the tumor proper.
After the enucleation is completed the capsule is washed with
a 1:5000 bichlorid solution and the compound tincture of
iodin applied to its entire inner surface. It is then packed with
a strip of iodoform gauze, one end of which is left projecting
from the vagina. This may be left in place for forty-eight,
or, if the temperature does not rise, for seventy-two hours.
At the end of this time the gauze is removed, and if no hemor-
rhage takes place, the parts may be washed once or twice a day
with a 1:5000 bichlorid solution. Should there be marked
bleeding, it will be necessary again to introduce the gauze.
The enucleation should be completed at one sitting if it is
possible to do so. The exhaustion of the patient may compel
the operator to desist before the mass is entirely enucleated.
The danger from sepsis and hemorrhage is very great in incom-
plete operations. The uterine cavity should, therefore, be washed
at least twice a day with a two per cent. carbolic solution, and
full doses of ergot given, with the hope of expelling the remainder
of the tumor by inducing uterine contractions. Should sep-
tic symptoms supervene, another attempt, which is usually
successful, should at once be made to complete the enucleation.
Fibroids of the cervix can nearly always be removed per
vaginam.
FIBROID TUMORS OF THE UTERUS.
603
!
Double Oophorectomy.—In July, 1872, Lawson Tait removed
the appendages for the purpose of controlling hemorrhage caused
by a bleeding fibroid tumor. The result was that in a few months
the hemorrhage ceased and the patient recovered perfectly.*
Up to three years ago Tait had removed the appendages in two
hundred and seventy-two cases for the same purpose. He con-
cludes most emphatically from his experience that oophorectomy,
for the purpose of controlling the intractable hemorrhage result-
ing from fibroids, is a perfectly justifiable procedure. As to the
results, of the fifty cases recorded up to 1882 only two have
proved to be failures. Of these, one was of the soft myomatous
variety. Tait has met with six cases of myomatous tumors, none
of which were benefited by oöphorectomy. Hegar also did much
to popularize this method of treating fibroids.
Oophorectomy for fibromata may be either very simple or very
difficult. If the tumor is small the appendages are easily secured
and removed. On the other hand when the tumor is large, and
especially if complicated by adhesions, the difficulties may be
not only very great but even insuperable. When one ovary is
found it is wise to locate the second before securing the first, for
but little relief would be afforded by the removal of one ovary
only. If it is decided to proceed with the operation, the tumor is
rotated in such a way as to expose as much as possible the append-
age first to be removed. The pedicle is secured in a Stafford-
shire knot and the appendage cut away. The second append-
age is secured and removed in the same manner. The abdomi-
nal wound is then closed in the ordinary way. Drainage is
rarely necessary.
•
Laparotomy for the Removal of Fibroid Tumors.-Only a small
per cent. of fibroid tumors give rise to symptoms sufficiently
urgent to justify or demand laparotomy for their removal. The
operation is not warranted at all until other resources having for
their object the relief of the distressing symptoms have been
exhausted. The conditions are very different from those which
present themselves in ovarian tumors. As we have seen in
* Birmingham Medical Review, May, 1889.
†Thornton recommends that the first ovary be left intact until the second is secured
and removed, so as to minimize the risk of bleeding from the first pedicle.
604
A TEXT-BOOK OF GYNECOLOGY.
studying the prognosis of fibroids, death rarely ensues from the
mere presence of a uterine fibroid. Then, too, the dangers attend-
ing hysterectomy are infinitely greater than those attending ovar-
iotomy. The average mortality in hysterectomy is from twenty
to twenty-five per cent., whereas the mortality in ovariotomy is
not over five per cent. This disparity is due to the greater diffi-
culty in controlling hemorrhage in hysterectomy, the greater
tendency to sepsis from sloughing of the pedicle, and the excessive
shock incident to the removal of a large, solid tumor. Finally,
as has been shown, the tumor usually ceases to grow after
the patient passes through the climacteric changes. Therefore,
so long as her life is not threatened or her health seriously im-
paired by the hemorrhages or by the pressure symptoms, it is
FIG. 132.

От
G.TIEMANN & CO
TAIT'S CORKSCREW FOR HYSTERECTOMY.
not necessary to interfere with the growth except in a pallia-
tive way. On the other hand, should an interstitial or sub-
peritoneal fibroid greatly interfere with the patient's comfort,
or threaten life because of pressure or hemorrhage, laparotomy
is indicated. After the abdomen is opened the choice between
oophorectomy and the removal of the growth can be made.
If the tumor is small and intimately attached to the uterus
oophorectomy is undoubtedly-in the light of the statistics fur-
nished by Tait, Hegar, and others—the preferable operation. If
the tumor is large, and especially if it is of the soft, myomatous
variety, it is best to end the laparotomy by removing it, together
with as much of the uterus as may be necessary.
FIBROID TUMORS OF THE UTERUS.
605
The patient is to be prepared as for ovariotomy. The ab-
dominal incision is made in the ordinary way, except that in
dealing with large tumors it is sometimes necessary to make
it very long—even extending from the pubes to the ensiform
cartilage. The tumor, if large, is lifted from the abdominal cavity
by one or more corkscrews (Fig. 132). The surgeon will first
observe the relation of the appendages to the tumor. Should the
growth spring from the fundus of the uterus it probably has not
carried the appendages with it and the ovaries and tubes will
be found low down in the pelvis. On the other hand, if its ori-
gin is in the lower uterine zone, the ovaries and tubes will be
located high up at the sides of the growth. The bladder should
be located by passing a sound into it. An elastic ligature (a
piece of strong rubber tubing will answer every purpose) is
thrown about the base of the tumor as far down on to the
cervix as it is possible to place it. After this is drawn tight and
secured in the blades of a strong pair of catch forceps, the hemor-
rhage will be entirely under control. As a general rule this
ligature will include the ovaries and tubes; should it not, it will
be necessary to ligate and sever the appendages separately.
Instead of the elastic ligature some operators prefer to use for
temporary constricting purposes either the clamp or the serre-
nœud. The tumor is now cut away, two or three inches above
the elastic ligature, after which the stump is cared for by one of
two methods presently to be described and the abdomen closed.
The after treatment does not differ essentially from that which
follows all abdominal sections.
Management of the Pedicle.-A great variety of methods have
been introduced for the management of the pedicle. They
resolve themselves naturally into the extra- and intra-peritoneal
methods.
Hegar's is probably
The elastic ligature,
purpose of tempor-
Of the various extra-peritoneal methods
the most simple and the one oftener used.
which was placed about the pedicle for the
arily controlling the hemorrhage, is left permanently in situ. The
stump is then secured in the lower angle of the wound, the
parietal peritoneum being stitched to that covering the pedicle
below the ligature. If necessary the ligature may transfix the

606
A TEXT-BOOK OF GYNECOLOGY.
pedicle instead of encircling it (Fig. 133). To prevent retrac-
tion and slipping of the ligature, it is best to transfix the pedicle
FIG. 133.
a
EXTRA-PERITONEAL METHOD OF
TREATING PEDICLE. (Hegar.)
(a) Method of closing abdominal
wound; (6) Method of transfix-
ing pedicle by elastic ligature.
above the ligature by a couple of
strong transfixion needles passed
transversely. The ends of the elas-
tic ligature are permanently secured
by a strong piece of silk. As much
of the stump as can be is now ex-
cised, after which it is cauterized
either by a saturated solution of
chlorid of zinc or by the Paquelin.
The elastic ligature usually comes
away about the eighth or tenth day.
Pean's Method.-The serre-naud is
used instead of the elastic ligature.
The wire of the serre-noud is kept
from slipping by two steel pins placed
above it. The stump is secured in
the lower angle of the wound, ex-
actly as in the method of Hegar,
except that the two opposing peri-
toneal surfaces are not stitched to-
gether. The cautery is applied to
the surface of the stump.
Bantock's Method. I will describe
Bantock's method as he himself has
carried it out many times in my pres-
ence. A temporary elastic ligature
is thrown around the tumor as low
down as it is possible to apply it.
Frequently it includes the upper portion of the vagina. The
upper half of the tumor is then cut away, leaving a stump at least
four inches long. A longitudinal incision is made anteriorly
through the peritoneum and underlying muscular layer, extend-
ing downward as far as the internal os. The peritoneum, together
with its subjacent structures, is next stripped from the stump to a
point corresponding with the lowest point of the incision in front.
The wire of the serre-naud is placed around the stump thus
FIBROID TUMORS OF THE UTERUS.
607
created, but does not include the peritoneum. Transfixing pins
are placed above the wire, when the stump is trimmed. The elastic
ligature is now removed. There is left, as it were, a hood of peri-
toneum encircling the stump. This is stitched to the parietal
peritoneum by quilted silkworm-gut sutures, underneath which
are placed strips of iodoform gauze to prevent cutting. This hood
of peritoneum not only shuts off the stump entirely from the
peritoneal cavity, but catches any discharge that may drop from
the stump proper. Any excess of peritoneum which projects
above the surface of the abdominal wall is cut away.
This operation is ingenious and, in the hands of Bantock,
most satisfactory. It is, however, a much more difficult opera-
tion than are Hegar's and Péan's, and, even in the hands of
its originator, the time required for its completion is much
greater.
Bantock packs about the stump iodoform gauze. If the
bleeding is profuse and is not controlled by the serre-naud, he
carries deep sutures under the bleeding points, and ties them.
Intra-peritoneal Treatment of the Pedicle.-The mortality
attending ovariotomy fell at once after the intra-peritoneal treat-
ment of the pedicle became popular. There are many objec-
tions to the extra-peritoneal method of treating the pedicle in
hysterectomy. It is necessary for the stump to slough before
the ligature or serre-nœud cuts its way through. This is always
attended with danger of sepsis, though the disintegrating process
is without the peritoneal cavity. The convalescence is much
more tedious than is the case in ovariotomy when the pedicle is
returned to the abdominal cavity. Then, too, a vagino-abdom-
inal fistula occasionally results, requiring for its closure a second
operation.
These various objections have induced operators to experi-
ment with the intra-peritoneal method of dealing with the
pedicle; and, indeed, some operators do away with the pedicle
entirely by removing with the tumor the whole uterus, together
with the cervix.* Those who have especially popularized the
* In subserous fibroids, when the pedicle is small and easily secured, all authorities
agree that the proper way of dealing with it is to secure it in a ligature and return it
to the abdomen, as in ovariotomy. I once returned to the abdomen a pedicle nearly
608
A TEXT-BOOK OF GYNECOLOGY.
intra-peritoneal method are Schroeder, Kelley, Sanger, Byford,
and Baer. Schroeder was one of the first operators who
practised the intra-peritoneal method of dealing with the stump.
He proceeds as follows:-
The broad ligaments and vessels are secured on either side of
the tumor with a double thread and divided. The elastic liga-
ture is then thrown about the stump thus formed, and the tumor
removed. A transverse wedge of tissue extending downward
to the elastic ligature is next excised from the stump; the cer-
vical mucous membrane is exsected with this.
All vessels are secured with catgut ligatures. The stump is
then closed by a continuous catgut suture, which is buried in
the tissues, the peritoneum being brought together over its sur-
face by interrupted silk sutures. The elastic ligature is finally
removed, the parts thoroughly cleaned, and the stump dropped
into the peritoneal cavity.
same.
The operation of Schroeder has been modified by various
surgeons, though the principles observed by all are much the
A decided innovation has recently been made by Baer
of Philadelphia. This operator secures all of the vessels of
the broad-ligaments in ligatures, and does not pass a single liga-
ture into or about the cervical tissue proper. The stump is
completely covered by the taut folds of peritoneum left behind.
In the extra-peritoneal treatment of the stump the pedicle is
separated by pressure necrosis. In order to prevent the tissues
from actually putrefying, various means have been resorted to.
Bantock simply applies absorbent wool, and maintains that this
alone is quite sufficient. Applications of tannin, alum, and strong
perchlorid of iron are used for the same purpose. The elastic
ligature keeps up a continuous tension, which controls the
hemorrhage and promotes the separation of the stump. If the
serre-nœud is used, a few turns of the screw should be made
every second or third day, or oftener should there be any evi-
dences of hemorrhage. Gauze, which should be frequently
changed, is kept packed around the pedicle so as to absorb all
three inches in diameter, after transfixing it with an elastic ligature (Medical Coun-
sellor, 1887.) The patient recovered without any untoward symptoms. Neverthe-
less, this practice should be limited to pedicles not larger than an inch in diameter.
FIBROID TUMORS OF THE UTERUS.
609
discharge. After the separation of the pedicle there is left a
deep granulating excavation. Ordinarily this becomes level with
the skin in the course of a week or ten days, and in the course
of another week or two skins over.
It sometimes becomes necessary to combine the intra- and
extra-peritoneal methods of treating the pedicle. In conduct-
ing the combined treatment where the pedicle cannot be brought
outside of the abdominal cavity without exerting too much
tension upon it, it is first secured by one or more ligatures,
the ends of which are fixed in the inferior angle of the wound
so that the pedicle is suspended from them. The serre-nœud
or elastic ligature may be used in the same way. The pedicle
is drawn for some distance into the abdomen and its margins
stitched to the parietal wound, so that the discharge cannot
escape into the abdominal cavity. Bantock's method of deal-
ing with the pedicle leaves behind a sufficient amount of peri-
toneum to permit of the adoption of this method very nicely,
should it be necessary. Some operators have surrounded it
with mackintosh sheeting in order to shut it off from the general
peritoneal cavity (Greig Smith).
As regards the relative mortality of the two methods, intra-
and extra-peritoneal, the advantages are as yet all on the side
of the latter, notwithstanding its many objections. This is shown
by the following table taken from Pozzi:-
a. INTRA-PERITONEAL METHOD.
Number of Deaths.
Operations.
b. EXTRA-PERITONEAL METHOD.
Number of Deaths. Mortal-
Operations.
Mortal-
ity.
Per Cent.
ity.
Per Cent.
Gusserow,
19
31.6
Kaltenbach,
5
3
60.0
Martin,
86
15
17.4
Bantock, .
Hegar,
Kaltenbach,
22
2
9.0
22
6
27.0
22
I
4.5
Olshausen,
29
9
31.0
Keith,
•
•
38
2
5.3
Spencer Wells,
26
ΙΟ
38.0
Péan,
•
52
18
34.0
Schroeder,
135
4I
30.0
Tauffer,
17
2
11.7
Tauffer,
12
4
33.0
312
88
24.10
Spencer Wells, 20
Lawson Tait,. 54
Thornton,
10
50.0
20
37.0
•
15
2
13.0
262 63
19.15
Myomectomy.—Myomectomy, or the enucleation of large sub-
peritoneal and interstitial fibroids through the abdominal cavity,
39
610
A TEXT-BOOK OF GYNECOLOGY.
was first introduced and popularized by A. Martin of Berlin.
He operates as follows: After controlling the hemorrhage by a
temporary elastic ligature, he splits the capsule by a long
incision, turns out the tumor, closes the capsule by stitching
its edges together with interrupted sutures, and, if it approaches
the vagina, drains through this canal.
Myomectomy is especially useful when the tumor is located
deep in the folds of the broad ligament. These tumors have
no pedicle and cannot be dealt with in the ordinary way. Instead
of closing the capsule, as recommended by Martin, and draining
from below, it may be stitched to the abdominal incision, as
recommended for incomplete ovariotomies, its cavity being
tightly packed with iodoform gauze. However, when the whole
uterus can be removed and the pedicle dealt with according to
the extra-peritoneal method, this is the preferable procedure.
Vaginal hysterectomy may be resorted to if the tumor is not
too large.
Removal of Fibroids During Pregnancy.-Fortunately, the vic-
tims of uterine fibroids are frequently sterile. When conception
does occur, peculiar dangers attend gestation. Early abortions,
which are of frequent occurrence, must be reckoned among these
dangers, although premature expulsion of the ovum is in such
cases to be accounted a piece of good fortune. Pregnancy in
most instances causes the tumor to grow very rapidly, so that
pressure symptoms soon become marked. This is especially
true of interstitial fibroids and fibroids springing from the cer-
vix. Not infrequently the growth undergoes edematous soften-
ing. The treatment will be determined by the circumstances. In
the case of pedunculated sub-mucous fibroids which project into
the vagina, the pedicle should be ligatured and divided. Should
the growth spring from the cervix and grow toward the vagina,
an attempt may be made to enucleate it without interrupting
gestation. Small subserous and interstitial tumors, situated high
up, may be left unmolested if the pressure symptoms are not
distressing, with the hope that pregnancy may proceed to term.
On the other hand, if life is threatened by the impulse which
the growth of the fibroid has received, it will be necessary
either to provoke a miscarriage or to open the abdomen. If the
FIBROID TUMORS OF THE UTERUS.
611
physician is inexperienced in abdominal surgery it will probably
be safer for him to empty the uterus if it is possible to do so.
There is, however, very great danger of fatal hemorrhage fol-
lowing this course. In two cases coming under my observation
the hemorrhage was only controlled by applying powerful styp-
tics directly to the endometrium. Had I again to contend with
similar cases I should pack the uterus with iodoform gauze.
Supravaginal amputation, in the hands of an experienced ab-
dominal surgeon, is, in my opinion, attended with little greater
danger than is the induction of abortion. Indeed, in large
tumors laparatomy is usually called for in the end, in order to
relieve the embarrassed organs. In this connection, the following
case is both interesting and instructive: On November 15, 1893,
Prof. N. Schneider of Cleveland, requested me to see with him
a young woman twenty-eight years of age, whom he saw for the
first time three days previously. She had been married six
months, and the menses had been suppressed for four months.
Her abdomen was enormously enlarged, emaciation was extreme,
and the digestion and circulation were greatly embarrassed.
The abdominal enlargement was symmetrical but peculiar. It
was almost pyramidal, the umbilical region being the most
prominent. The tenderness was very marked. Digital examina-
tion revealed the cervix in the hollow of the sacrum and to the
left, and almost obliterated. The finger could only penetrate the
external os. In the anterior fornix a large globular mass, con-
tinuous with the tumor above, could be distinctly felt.
Whether the body felt was an extra-uterine fetus, an intra-
uterine fetus, or an adventitious growth we could not determine.
The patient declared that she felt motion up to two weeks before
the examination was made. There was no history of false labor
and no history of shock and collapse, such as usually attend
primary rupture in extra-uterine pregnancy. The fetal heart
sounds could not be heard. As a girl, the abdomen was en-
larged, though the menstrual discharge was never excessive.
It was clearly evident that the patient was dying from the
exhaustion induced by the pressure of the tumor, whatever its
nature. She was removed to the Huron Street Hospital in an
ambulance and placed under an anesthetic on November 17th,

612
A TEXT-BOOK OF GYNECOLOGY.
two days after our first examination. An attempt was first
made to dilate the cervix and explore the uterine cavity. The
sound penetrated the uterus for a distance of two inches, but, for
reasons which will appear later, the fetus could not be felt with
the finger. Accordingly, after plugging the uterus and vagina
with gauze the abdomen was opened. The incision, which was
central, brought into full view the tumor shown in Fig. 134.
FIG. 134.
A PREGNANT UTERUS, TOGETHER WITH A SUB-SEROUS FIBROID WEIGHING
TWENTY-FOUR POUNDS, REMOVED BY SUPRA-VAGINAL HYSTERECTOMY.
THE BRISTLE PENETRATES THE CERVICAL CANAL. (Wood.)
An incision extending from the pubes to the ensiform cartil-
age was required in order to deliver it. The uterus contained
a four months' fetus and the cervix contained a second tumor
as large as a fetal head. This was why the finger could not
penetrate the uterine cavity. Several smaller tumors projected
from the surface of the fundus. There was but one thing to do
under the circumstances, namely, remove the uterus and appen-
dages with the tumor. In this opinion Prof. Schneider con-
FIBROID TUMORS OF THE UTERUS.
613
curred. This was done by first throwing about the cervix, low
down, an elastic ligature. The cervix was then amputated
above the ligature, after which the serre-naud was applied and
the ligature removed. The abdomen was washed with sterilized
water and the utero-vesical pouch, which continued to ooze
blood, was tamponed according to the method of Mikulicz. This
was the only form of drainage used. The abdomen was closed
in the usual way.
The patient rallied from the operation but died thirteen hours
later from shock. I firmly believe that had the abdomen been
opened a month earlier her life might have been spared. The
case is a most interesting one for several reasons: It illustrates
the impulse given to the growth of fibroids by pregnancy; it
illustrates the difficulties which may attend the diagnosis of
rapidly growing tumors complicating pregnancy; finally, it
illustrates also the difficulties and dangers which may be encoun-
tered in attempting to empty the uterus through the cervical
canal.
Unless the pedicle is very small in subserous and interstitial
tumors, I think that supravaginal amputation is safer and
more satisfactory than is simple myomectomy.
FIBRO-CYSTIC TUMORS OF THE UTERUS.
Fibroid tumors of the uterus may, as we have seen, undergo
degeneration and form cysts, or, rather, pseudo-cysts. The result-
ing fluid is not included in a special cyst wall, hence the term
"cystic," as applied to these growths, is somewhat misleading.
This form of degeneration is of rare occurrence, although it
may take place in any fibroid tumor of the uterus. Its cause is
uncertain. Koeberle suggests a possible lymphatic origin in
certain instances. Whatever the cause, serum finds its way
between the bundles of fibrous tissue throughout the mass. The
spaces thus formed are divided by septa or trabeculæ, which in
time become broken down, producing one or more large cavities.
Subserous fibroids oftener undergo cystic degeneration.
The symptoms do not differ essentially from those of large
fibroids in general. It is maintained that the health of the
patient is less often seriously affected than is the case with solid
614
A TEXT-BOOK OF GYNECOLOGY.
tumors (Thomas and Mundé). If the cavity, or cavities, are at
all large, fluctuation may be detected. It is then extremely
difficult to differentiate fibro-cystic tumors from ovarian cysts.
As a rule, the differentiation is not made before the abdomen is
opened, the surgeon until then thinking that he has to do with
an ovarian tumor. Even if tapping is resorted to there is
nothing pathognomonic about the character of the fluid. It was
claimed by Atlee that fluid which coagulates as soon as exposed
to air, and in which is formed a colorless blood-clot, is suffi-
ciently characteristic to distinguish fibro-cystic tumors of the
uterus from ovarian cysts. Later observation has not confirmed
this claim.
The examiner will, then, be led to suspect the presence of a
fibro-cystic growth when a large, indistinctly fluctuating tumor
exists for a long time without seriously compromising the
general health of the patient; when physical exploration con-
nects such a tumor with the uterus; when the uterus is drawn
upward toward the abdominal cavity; and, finally, when the
uterine cavity is markedly increased in size. The uncertainty of
diagnosis previously to opening the abdomen is, notwithstanding
the foregoing symptoms, usually very great.
The treatment does not differ from the treatment of fibroids in
general, except that the attachments in fibro-cystic tumors are
usually more extensive and the vascularity greater. Should
extirpation prove too hazardous after the abdomen is opened,
the cyst cavity may be stitched to the abdominal wall, as is
recommended in incomplete ovariotomy. The cavity is then
packed with gauze. As a palliative measure, tapping may be
resorted to when more radical treatment is not expedient. This,
however, should never be done if it is possible to remove the
tumor without too great risk.
Electricity is entirely inapplicable in dealing with these
growths.
#
CHAPTER XL.
POLYPI OF THE UTERUS: THERAPEutics of
UTERINE FIBROMA AND POLYPI.
Varieties. Since the term polypus, as ordinarily applied,
signifies the form of tumor only, it is proper to include under
the head of polypi of the uterus the following varieties:—
1. Fibrous polypi, which are pediculated submucous fibroids
in the process of extrusion;
2. Mucous polypi, springing from the mucous membrane ;
3. Enlarged cystic follicles, which have become pediculated;
4. Placental polypi, the result of the retention of a portion of
the placenta, following abortion or labor at term.
I. Fibrous Polypi.-Fibrous polypi are nothing more than
fibroid tumors forced into the uterine cavity by uterine contrac-
tions. They have their origin in the muscular walls of the uterus,
in the larger number of instances springing from its body. When
incised, they show the same firm consistence as do fibroid
tumors. They vary in size from that of a walnut to that of an
adult head, and are usually of a symmetrical or pyriform shape.
Fig. 135 shows such a polypus yet within the uterine cavity.
Fig. 136 shows a tumor partly projecting from the external
uterine orifice, while Fig. 137 shows one completely extruded
from the vagina, with the pedicle much elongated and con-
stricted by pressure.
After the polypus passes into the vagina, if large, it may inter-
fere with the functions of the bladder and the rectum. Occasion-
ally the tumor becomes adhered to the vagina, suggesting that
the growth is of vaginal origin.
In the preceding chapter it was noted that when an intersti-
tial fibroid grows toward the uterine cavity it excites uterine
contractions, by which process pediculation and extrusion are
accomplished. As the tumor becomes more and more poly-
615

616
A TEXT-BOOK OF GYNECOLOGY.
poidal in shape, the uterus becomes less and less tolerant of its
presence. The length of the pedicle varies greatly. It may not
be long enough to permit the polypus to be forced from the
uterus, or its length may permit it to hang without the vagina.
FIG. 135.
4608
A UTERUS CONTAINING A FIBROUS TUMOR IN THE PROCESS OF PEDICULATION.
(Museum R. C. S. Photographed by the Author.)
Fibrous polypi are, as a rule, sparingly vascular. The men-
orrhagia and metrorrhagia, which so frequently result from their

POLYPI OF THE UTERUS.
FIG. 136.
G.D.
617
SUBMUCOUS FIBROUS POLYPUS PROJECTING INTO VAGINA. (Auvard and Devy.)
FIG. 137.
FIBROUS POLYPUS SPRINGING FROM CERVIX. (Wood.)
The patient suffered for six years with a tumor of some kind within the vagina which
was supposed to be prolapsus uteri. The tumor escaped from the vagina three
days before I saw her, when, owing to constriction, it rapidly enlarged and
became exceedingly offensive. The temperature at the time of entering the
hospital was 106°, but quickly dropped to normal after the mass was removed.

618
A TEXT-BOOK OF GYNECOLOGY.
presence, are due to the existing endometritis, the blood pro-
ceeding from the uterine mucous membrane.
2. Mucous Polypi.-These are oftener located in the cervix.
They rarely attain a size larger than that of a walnut, and
usually are smaller than this. They are of a soft, pulpy consist-
ence. Unlike fibrous polypi, they are extremely vascular, and
are made up, histologically, of the same structure as that of the
mucous membrane from which they spring. Occasionally,
microscopical section shows also stratified epithelium similar to
that found in the vaginal portion of the cervix.
FIG. 138.
When this
VASCULAR MUCOUS POLYPUS GROWING FROM INNER WALL OF UTERUS.
(Museum R. C. S. Photographed by the Author.)
epithelium is found these growths may be the starting point
of malignant disease (Underhill). When they spring from the
body of the uterus, the ducts and cysts are lined with ciliated,
cylindrical epithelium (Hart and Barbour). Fig. 138 shows a very
large mucous polypus springing from the body of the uterus.
This location, as already indicated, is most unusual. Fig. 139
shows the usual appearance of these growths when located in
the cervix. They are rarely single, and frequently as many as
eight or ten exist together.

POLYPI OF THE UTERUS.
619
3. Enlarged Cystic Follicles which have become Pedicu-
lated. These have already been referred to under the head of
cystic degeneration of the cervix (v.p.431). They are known also
as glandular polypi. They are merely hypertrophied Nabothian
follicles distended with fluid. More or less hypertrophy of the
cervical canal attends their growth. The glands of the body of
the uterus proper may likewise undergo degeneration. Such a
condition is shown in Fig. 140. These polypi rarely become
larger than a bean, though they may reach a size equal to that
of a pullet's egg. They are usually of a benign character.
FIG. 139.
FIG. 140.
MUCOUS POLYPI. (Schroeder.)
ENLARGED PEDICULATED CYSTIC
FOLLICLES. (Beigel.)
A few cases are reported where these growths, springing from
the cervix, have developed to a size sufficient to fill the vagina,
and even to protrude from the vaginal orifice. When they attain
this size they are made up of tissue partly glandular, partly
colloid, and, in nearly all instances, partly malignant or sarcoma-
tous.
Pfannenstiel * reports a most interesting case of this kind.
The patient was 53 years of age and had always been healthy.
Five
years after the menopause she began to have local distress.
An examination revealed a polypus springing from the anterior
*Münchener Medicinische Wochenschrift, September, 1891.
620
A TEXT-BOOK OF GYNECOLOGY.
cervical wall which extended to the vulva. The tumor con-
sisted of a grape-like mass. It was removed with a sharp spoon
curette and its base seared over with the Paquelin. A micro-
scopic examination showed it to be sarcoma. The entire
uterus was then removed per vaginam, but the growth returned
six months later in the left half of the vaginal cicatrix. Up to
that date the author was able to find recorded in the literature
only eleven cases of the kind.
Thomas, Mundé, and Fenger, of this country, have each
reported similar cases.
*
4. Placental Polypi.-These are formed by the incomplete
detachment of the placenta, a few of the villi remaining behind.
Around this small mass of placental tissue blood coagulates and
fibrin is deposited. Polypi of this origin may continue to
increase in size until a tumor of some dimensions is produced.
This condition is classified under the head of "Polypi," simply
because of the shape of the tumors formed; they are not new
formations.
Symptoms.-Hemorrhage is the most frequent and constant
symptom. In fibrous polypi it is due to the endometritis result-
ing from the presence of the tumor; in mucous polypi it pro-
ceeds from the tumor itself as well as from the hypertrophied
uterine mucous membrane. It manifests itself first in a gradual
increase in the menstrual flow; and as time goes on it may
become intra-menstrual, not infrequently exsanguinating the
patient. The quantity of blood lost by no means depends upon
the size of the tumor, a very small mucous polypus giving rise
to profuse and even fatal hemorrhage.
The anemia induced by the loss of blood is, in some cases,
* Under the head of “Adenoma of the Uterus," Coe (Journal of the American
Medical Association, July, 1891) states that there is but one variety of true cervical ade-
noma, and that is malignant. This assertion is based upon the fact that the disease is not
confined to the mucous membrane, but invades the underlying muscular layers. The
growth of the tumor is exceedingly slow. It is, nevertheless, fatal unless removed.
Coe advises total extirpation as the only treatment to be considered; curetting appears
to hasten the tendency to malignancy. Pozzi also includes under the head of cancer
of the corpus uteri adenoma of the uterus. Malignant adenoma is, according to the
author last named, the initial process of cancer of the mucosa. There yet exists
more or less confusion relative to these growths of the uterus.
POLYPI OF THE UTERUS.
621
most striking-at times suggesting the cachexia of carcinoma.
Should an offensive leucorrhea accompany the hemorrhage,
there is danger of mistaking it for malignant cachexia.
The next most constant symptom is leucorrhea. Like the
hemorrhage, it is due to the existing endometritis. It is rarely
offensive except when the polypus sloughs.
Menstruation is often most painful. The suffering is due to the
polypus interfering with the exit of the menstrual blood, as well
as to the exaggerated uterine contractions resulting from the
presence of the tumor.
Sterility must also be included under the head of symptoms.
It is due both to mechanical causes and to the endometritis.
Diagnosis.—If the tumor does not protrude from the uterine
cavity into the vagina, it will be impossible to determine the
cause of the uterine enlargement without first dilating the cervical
canal. Sometimes the tumor presents at the external os only
during menstruation. It is, therefore, well to make an examina-
tion at this time when the presence of a polypus is suspected.
In fibrous polypi a bimanual examination will show that the
uterus is enlarged. After the cervix is dilated the finger and
sound will indicate the situation of the pedicle, as well as its
size.
Should the polypus be of placental origin, it is easily detached
by a dull wire curette. It is rarely necessary to dilate the cervix
in dealing with this form of polypi.
Mucous polypi springing from the cervix can ordinarily be
detected by digital examination. Their characteristic form and
color will be observed after the speculum is introduced.
There will be no difficulty in detecting the presence of a
fibrous polypus when it finds its way into the vagina. There is,
however, some danger of mistaking a large polypus thus located
for an inverted fundus uteri. This mistake has more than once
been made. The uncertainties are increased when inflammation
and adhesions exist. In order to differentiate the two conditions
let the examiner proceed as follows:—
First, determine if possible, the location of the fundus uteri by
abdomino-vaginal examination. If it is in its normal position
the vaginal tumor is probably a polypus. Should it be an
622
A TEXT-BOOK OF GYNECOLOGY.
inverted fundus, and the conditions are favorable, the truncated
end of the uterus may be detected through the abdominal wall.
If the abdominal walls are unusually thick or tender, so that the
bimanual is unsatisfactory, the sound may be passed into the
bladder and the finger into the rectum. In this way the pre-
sence or absence of the fundus between the finger and the sound
can be determined. If the tumor within the vagina is a poly-
pus, and adhesions do not exist between its pedicle and the
cervix, the sound will penetrate the uterine cavity for at least two
and a-half or three inches; if it is an inverted fundus, the sound
cannot be passed.
It must not be forgotten that a partial inversion is frequently
associated with a polypus.
Prognosis. The prognosis, in the absence of malignancy,
is usually favorable. If the polypus endangers life it is because
of the hemorrhage excited. Mucous polypi springing from the
cervix are removed with but little difficulty. The removal of
fibrous polypi may be attended with greater risk. Ordinarily,
however, when pediculation is complete there is no special
difficulty attending their removal.
Treatment. This is entirely surgical. A polypus of any de-
scription should be removed as soon as it is discovered, unless
urgent counter indications exist.
Mucous polypi may be seized with a pair of strong catch forceps
and twisted off or excised. It is my practice to touch the base
of a tumor thus removed with the Paquelin cautery.
Placental polypi are easily removed with a curette, after which
the uterine cavity should be cleaned and the compound tincture
of iodin applied.*
In dealing with fibrous polypi it is important to determine
accurately the location and size of the pedicle. The cervix may
be dilated, either rapidly under ether, or by the use of tents.
Personally, I prefer the rapid method. If it is possible to locate
the pedicle, it may be divided with curved scissors guarded by
* Rosenburg reports, in the Internationale Klinische Rundschau, November, 1889,
a case of abortion at the sixth month, where the placenta could not be removed and
became septic. As a forlorn hope, vaginal hysterectomy was performed. The
patient made a speedy and perfect recovery.
POLYPI OF THE UTERUS.
623
the finger, or with a polytome (Fig. 141). Unfortunately, this can-
not always be done, the size of the tumor interfering with the
manipulations. In this event, if the pedicle is not too thick, it
may be separated by torsion. When cutting instruments are used
great care must be observed not to injure the walls of the uterus,
the scissors or polytome at all times hugging the surface of the
tumor. The possibility of a partial inversion should constantly
be borne in mind, for there is always danger, when this compli-
cation exists, of cutting into the uterine tissue. The old practice
of separating the pedicle by ligature or écraseur is now practi-
cally abandoned. If the écraseur is used, it is better to connect
the wire with the galvano-cautery.
A very large tumor may so interfere with intra-uterine and
intra-vaginal manipulations as to make it necessary to incise the
mass before attacking the pedicle.
FIG. 141.

TIEMANN-CO-NY
AVELING'S POLYTOME.
Should the hemorrhage not be controlled by the cautery,
gauze packing may be resorted to.
I think that it is entirely possible to relieve by internal medi-
cation many of the distressing symptoms, particularly the
hemorrhages, which are incident to uterine fibroma and polypi.
Whether or not these growths can be actually cured by internal
medication is a question about which there is a wide difference
of opinion. I cannot better express my own views on this sub-
ject than to quote the words of Dr. Ludlam. He says:
He says:* "In
claiming that these tumors are curable in their incipiency by
means that are so mild and variable, I do not forget that there
are many sources of failure which might lead to a wrong infer-
ence respecting the efficacy of this entire plan of treatment. It
*" Medical and Surgical Lectures on the Diseases of Women." 1888.
624
A TEXT-BOOK OF GYNECOLOGY.
is not unusual for these growths to increase or decrease in size
very rapidly, and sometimes to disappear spontaneously. A
retrograde metamorphosis may take them out of the way, the
climacteric may arrest their development, and other changes may
cut off their nutrition and cause them to wither. These cures
by limitation are often placed to the credit of such agencies as
animal magnetism, spiritualism, electricity, and other imponder-
ables, even of medical treatment. But making due allowance for
all these exceptional cases, I apprehend it remains that very great
good of a positive kind may be done by means of fitly chosen in-
ternal remedies."
Therapeutics of Uterine Fibroma and Polypi.
Lachesis.-Uterine region feels swollen; will bear no contact,
not even of the clothing; bearing down pains; uterine and ovarian
pains relieved by the flow of blood; leucorrhea copious, smart-
ing, stiffening the linen and staining it greenish; suitable at the
menopause, with flushes of heat, hot vertex, metrorrhagia, and
fainting.*
Belladonna.-Much bearing down in the pelvis; metrorrhagia
of bright red blood, or thick, decomposed, dark red blood; the
genital organs are sensitive, and there is much throbbing in them;
plethoric patients; menses too early and too profuse.
Calcarea iodid.-Menses too early, too long, and too pro-
fuse; acidity of the stomach; milky leucorrhea, with itching and
burning.†
*“ Lachesis seems possessed of remarkable virtues as a resolvent, particularly
where there is defective involution of the womb."- Ludlam.
"The indications for Calcaria iodid in the treatment of uterine myomas are not
well understood. It seems to be more effectual in causing a gradual diminution of the
tumor than any other remedy, and in doses too small to act on the theory of calcifi-
cation of the growth and interference with its nutrition. It is significant that the
most celebrated mineral waters for the cure of fibroids contain a large amount of lime
salts. Good results have been reported from the third decimal trituration. It has
also been recommended in the shape of ten grains to a pint of water, a teaspoonful
to be taken after each meal, gradually increasing to a tablespoonful. This may act
very similarly to chlorid of calcium in possibly causing a calcareous degeneration of
the tumor; but, as it has been found that the coats of the arteries are also likely to
undergo the same degeneration, the remedy may become a dangerous one. It seems
quite probable that it can influence the nutrition or development of these tumors in a
certain number of cases without being given in a sufficient quantity to induce the
degeneration alluded to."--Southwick.
THERAPEUTICS OF UTERINE FIBROMA AND POLYPI. 625
Secale cor.-Menses too profuse and last too long, with tear-
ing and cutting colic; cold extremities; cold sweat; great weak-
ness and small pulse. Passive hemorrhage of fetid or dark blood;
leucorrhea, brownish and offensive.*
Trillium.-Gushing of bright red blood from the uterus on the
least movement; weak sight; anxious look; patient is pale and
faints easily; flow returns every two weeks. †
Ferrum.-ANEMIA FROM LOSS OF BLOOD; sticking, shooting
pains in the uterus; menses too late, too long lasting and pro-
fuse; the flow is watery and preceded by labor-like pains;
hysterical symptoms after menses; alternate redness and paleness
of face.
Sabina. Menses too profuse and too early, with colic and
labor-like pains in uterus; stitches from below upward in vagina;
metritis with hemorrhages; blood dark and corroding and some-
times offensive.
China.-Uterine hemorrhages of dark, clotted blood, with
fainting and muscular twitching; prostration from loss of blood.
Platina.-Painful sensitiveness in the region of mons veneris
and genital organs; induration of uterus and frequent sensations
as if the menses would appear; pruritus vulvæ; voluptuous ting-
ling with anxiety and palpitation of the heart; vulva painfully
sensitive during coitus.
Plumbum.-Hemorrhage with sensation of a string pulling
from the abdomen to the back; climacteric period; dark clots
alternating with fluid blood or bloody serum, with a sensation of
fulness in pelvis.
* “ I have frequently obtained temporary ameliorations of the symptoms produced by
the pressure of a fibroid with an apparent shrinking of the tumor by the use of Secale
cor. in a low attenuation. The drug is, however, usually given by hypodermic injec-
tions in from three to six drops of Squibb's solution two or three times a week.
Simpson recommends the following formula :—
Ergotinæ,
Aquæ,
Chloral hydrate,
zij
3 vj
3 ss.
Mix.
Twelve minims of the solution to be used at each injection.". Cowperthwaite.
† “Trillium seems to be especially adapted to the menorrhagia and metrorrhagia
which are almost always present in cases of interstitial and intrauterine fibroids, for,
like Secale, it is of little use in uterine hemorrhage unless, from pregnancy or otherwise,
the muscular fibers of the womb have been decidedly developed."-Ludlam.
40
626
A TEXT-BOOK OF GYNECOLOGY.
Sulphur.-Menses too late and of short duration, or sup-
pressed; before menses headache; cough in the evening; nose-
bleed; bearing down in pelvis toward genitals; stitches or
pressing pain in region of liver; constipation, stools hard, knotty,
insufficient; skin rough and scaly.
Conium mac.-Induration and prolapsus of the uterus with
lancinating pains; acrid and burning leucorrhea, preceded by
pinching pains in abdomen.
Kali hydriod.-Fibroid tumors with much emaciation and
prostration; menorrhagia; dysmenorrhea, and constant leucor-
rhea.
Ledum.-Fibrous tumors with menorrhagia; displacement of
uterus; profuse leucorrhea; abundant urination.
Silicea.-Amenorrhea with great debility; profuse, acrid, ex-
coriating leucorrhea; morbid perspirations.
Consult.-Sabina, hamamelis, pulsatilla, nitric acid, calcaria
carb., china, ipecacuanha, and sepia.
CHAPTER XLI.
MALIGNANT DISEASES OF THE UTERUS.
CARCINOMA OF THE CERVIX.
General Considerations and Etiology. It is estimated
that cancer of the uterus is located in the cervix in 97 per cent.
of all cases met with. It is also estimated that of the total male
mortality death is due to carcinoma in about 0.97 per cent. of
all cases, whereas among women it is the cause of death in 2.2
per cent. of all cases.* Notwithstanding this great disparity,
the mortality of the two sexes from carcinoma is the same pre-
viously to the age of puberty. After this period the relative
proportion of female to male mortality from this disease gradu-
ally rises until the age of fifty, at which time it reaches its
maximum in women.
Cancer is located in the uterus in one-third of the total cases
occurring in women. Next in frequency, as regards location,
are the mammary glands.
Various theories have been put forth by different pathologists
to explain the great predisposition of the cervix to malignant
neoplasms. It is suggested by Cohnheim that the embryonic
cells (embryo-plastic cells of Robin) which are found dissemi-
nated throughout the connective tissue, or accumulated at certain
points, constitute the fundamental tissue of carcinoma. The
involution of the blastodermic layers is more irregular at the
natural orifices of the body, and, therefore, these orifices are the
seats of predilection for nests of embryo cells. The cervix,
developed relatively late from Müller's tubes, is particularly
rich in these nests of embryo cells. There also exist at the
cervical opening two kinds of epithelium, which create a tend-
ency to plastic paramorphism (Pozzi). These peculiarities, it is
claimed, make the cervix congenitally vulnerable to the invasion
of carcinoma.
* Hart and Barbour, “Manual of Gynecology," 1883, p. 436.
627
628
A TEXT-BOOK OF GYNECOLOGY.
In addition it will be necessary to note as predisposing factors:-
Heredity;
Age;
Childbearing;
Race;
Depreciation of vital forces.
Heredity.—Undoubtedly the importance of hereditary influen-
ces has been greatly over-estimated in the past. According to
Gusserow, it has been proven to exist only in about 7.6 per cent.
of all cases; Schroeder places the estimate at 8.2 per cent. ; and
Winckel at 6.3 per cent. The statistics bearing upon this sub-
ject have been largely drawn from hospital cases, and hospital
patients, it must not be forgotten, often know very little of their
antecedents.
Age. The larger percentage of cases occur between the ages
of forty and fifty. I will again quote from Gusserow. These
statistics should be compared with those of fibroid tumors given
on page 592.
Gusserow's statistics:-
Out of 2270 cases
2 were under 20 years,
81
between 20 and 30 years,
476
""
30 40
66
771
66
600
258
"6
(6
40 50
"60
50
60
(6
70
82
over
70 years. (Hart and Barbour.)
It will be observed from the foregoing that the number of
cases occurring under the age of puberty (two) is very insignifi-
cant; yet cancer of the uterus has been discovered in children.
Mundé has met with a case in a girl of eighteen, and Zweifel
removed the uterus, per vaginam, from a girl of thirteen for
epithelioma of the cervix.
Childbearing.-Winckel's statistics show that of multiparous
women victims of cancer the average number of children was
8.2 per cent. Hofmeyer, in a series of 812 cases of carcinoma,
found only 4.8 per cent. of nulliparæ. In Winckel's series of
cases sterility was present only in 1.7 per cent. It is observed
by most authorities that miscarriages and abortions frequently
precede carcinoma of the uterus.
MALIGNANT DISEASES OF THE UTERUS.
629
Race.—The African race, although especially liable to fibroma
uteri, seem to enjoy greater immunity from carcinoma of the
cervix than do other races. Kelley has recently reported two
cases of cancer of the cervix in negresses.*
Depreciation of Vital Forces.-Unlike fibromata, carcinomata
occur much oftener among the poor than the rich. This is
probably due to the depraved nutrition so much more preva-
lent among the former class, as well as to the greater physical
exertion and exposure to which they are subjected.
Of the exciting causes, anything that will keep up an active
irritation tends to produce a rapid production of cells and
papillæ. If constant stimulation and irritation are kept up by any
of the enumerated causes, carcinoma is liable to result, particu-
larly in one predisposed to it. Cervical lacerations cause an
eversion of the mucous membrane, and subject it to constant
friction against the vagina as well as to irritation during coitus.
Protracted catarrh will likewise perpetuate irritation and
congestion. It is probable that the frequent occurrence
of lacerations and cervical catarrh following parturition is the
reason why cervical cancer occurs oftener in multiparæ. The
deposition of cicatricial tissue unquestionably plays an important
part in the production of malignancy.
Varieties and Pathology.-Any of the following forms of
cancer may attack the cervix :-
Encephaloid or soft cancer;
Scirrhous (fibrous or hard cancer);
It is often
Epithelioma (superficial or epithelial cancer).
'This division is, to a large extent, arbitrary.
impossible to determine the original form of the disease after
the tissues are broken down. The distinction between encepha-
loid (medullary), and scirrhous cancer, is largely one of degree.
In the former, the cellular element predominates; in the latter,
the fibrous stroma. According to Thiersch and Waldeyer
these two forms have their origin in epithelial cells (either the
squamous which cover the vaginal surface of the cervix; or the
cubical which line the cervical canal). According to Virchow,
they start from the connective tissue cells of the cervix.
*"Transactions of the Southern Surgical and Gynecological Association," 1891.

630
A TEXT-BOOK OF GYNECOLOGY.
Epithelioma of the cervix occurs in two forms: (1) The flat,
which gives rise to superficial ulceration within the canal
and causes excavations. (2) The papillary (Fig. 142), which
springs from the deep layers of squamous epithelium on the
vaginal aspect of the cervix (Thiersch and Waldeyer); this,
FIG. 142.
4661
EPITHELIOMA OF THE CERVIX.
A ligature is tied around a part of its base, its substance having been broken through.
The uterus is enlarged and its cavity dilated; on its left wall there is a small flat
growth, half an inch in diameter, like a mucous polypus. The ovaries are both
adherent to the sides of the uterus and the broad ligaments are thickened.
(Museum R. C. S. Photographed by the Author.)
instead of excavating the cervical canal, grows downward into
the vagina in the form of a cauliflower excrescence. Encephaloid
and scirrhous cancers grow very rapidly, quickly invade the con-
nective tissue, and produce early metastasis. On the other
MALIGNANT DISEASES OF THE UTERUS.
631
hand, epithelioma progresses slowly, spreads by extension, and
does not produce metastasis until late.
Symptoms. The symptoms vary greatly in different cases.
One of the earliest and most constant is hemorrhage. If the
patient has passed the menopause, it is often noticed for the first
time after straining at stool or after coitus. Before the meno-
pause it frequently begins as a menorrhagia, menstruation sooner
or later becoming irregular without any apparent cause.
It
occurs earlier in epithelioma growing toward the vagina.
During the first stages it proceeds from the vascular stroma of
the growth, the numerous delicate vessels readily rupturing.
Later on, if profuse, it is due to destruction of one of the
larger vessels. Immediate death rarely, if ever, is caused by the
hemorrhage.
The next most constant symptom is a vaginal discharge. This
frequently alternates with menorrhagia. At first it is watery
and not particularly offensive. After necrosis of tissue takes place
it is tinged with blood, and possesses a most penetrating and
offensive odor. This odor cannot well be described, yet it is
peculiarly characteristic, and when once observed will be readily
detected. The leucorrhea becomes excoriating, and the irritation
of the vulva and thighs is sometimes very great. Decomposing
blood-clots and threads of gangrenous tissue are often expelled
with the discharge during the later stages of the disease.
Pain does not occur until infiltration of the adjacent structures
takes place. There is nothing about the pain of carcinoma that
is characteristic, although it is usually spoken of as shooting,
lancinating, or stabbing in character. The patient not infre-
quently locates it in the center of the pelvis, from which it radi-
ates to the lower portion of the back and groins, or extends
down the inner sides of the thighs. Unlike the pain of chronic
inflammation of the uterus it is usually aggravated at night. It
is often most distressing and even insupportable.
Cachexia sooner or later makes its appearance. It is due to
the absorption of débris, to the exhausting serous discharge, and
to the hemorrhage which so frequently attends the disease. In
time a malignant toxemia is induced, due to the diminution of
the albumin and red blood corpuscles, with an increase in the
632
A TEXT-BOOK OF GYNECOLOGY.
watery constituents of the blood. As a result the skin takes on
a peculiar sallow, or dirty straw-colored tint.
Early and progressive emaciation is very characteristic of can-
cer. The nutrition becomes seriously impaired. This is due to
various causes, one of the chief being the offensive fetor result-
ing from the discharge.
The disease frequently involves the bladder and the rectum,
seriously interfering with the functions of both of these organs.
When it extends toward the bladder dysuria may be the first
symptom calling the attention of the patient to the pelvic organs.
Not infrequently the ulceration extends into the bladder and a
vesico-vaginal fistula is thus formed. If the rectum is invaded
defecation becomes painful, or even impossible.
Physical Signs.-Unfortunately, in by far the larger number
of cases, the physician does not have an opportunity to practise
physical exploration until after the disease is considerably ad-
vanced. Few women deem an examination necessary until
some of the symptoms which have been studied make their
appearance. The disease during its early stages will be found
almost invariably located at the external os; thence spreading, as
the case may be, upward along the cervical canal, downward into
the vagina, or into the deeper tissues of the cervix. After the
stage of ulceration, the finger will feel an irregular surface with
hard, unyielding margins; or, in the case of papillomatous
tumors (cauliflower excrescences) a soft, friable mass projecting
into the vagina. Upon withdrawing the finger it will be stained
with blood and the characteristic odor will be recognized.
In scirrhous cancer, the cervix is increased in size, its surface is
irregular or nodulated, and the tissues are indurated. The tender-
ness is not marked. The mucous membrane covering the
diseased area is fixed to the underlying tissues.
The experienced examiner will be able to obtain more definite
information from digital exploration than from a specular
examination. Great care must be observed in using the specu-
lum after the ulcerative process has begun. The irregularly
ulcerated surface, with unyielding margins, will be seen
through the speculum; or, should the case be one of cauliflower
excrescence, a papillomatous mass will project into its field.
MALIGNANT DISEASES OF THE UTERUS.
633
In case of doubt, the final test must be the microscope. If a
portion of the tissue is removed and prepared for microscopical
examination, there will be found irregular cells of an epithelial
type, with one or more large nuclei, surrounded by a fibrous
stroma with alveoli. These cells are characterized by their large
size and by their prominent round or oval nuclei, which con-
tain one or more bright red nucleoli. It is the mode of distri-
bution of the cells in the meshes of the fibrous stroma that
determines malignancy; there is no pathognomonic cancer cell.
While the foregoing symptoms are characteristic of a typical
case of cancer of the cervix, it is necessary to remind the reader
that the disease may reach an advanced stage before any of the
symptoms enumerated make their appearance. The pain may
be nearly or entirely absent. The offensive discharge is not
always present, even when there exists necrosis of tissue. Hem-
orrhage is by no means a constant symptom. The physician
should, therefore, be upon his guard. Since vaginal hysterec-
tomy has become a popular and beneficent operation, it is all-
important that an early diagnosis should be made. Slight, irreg-
ular hemorrhages, occurring during the inter-menstrual period, or
after coitus, call for immediate local examination. If, upon making
such an examination, there should be found induration of the
cervix with an easily bleeding erosion, a wedge-shaped portion
of tissue should be excised for microscopical examination.
Differentiation.-The conditions which simulate cancer of
the cervix are :—
Syphilitic ulceration;
Areolar hyperplasia of the cervix ;
Papillary erosion, with ectropium and cicatricial deposits;
Sloughing fibrous polypus;
Retention of the products of conception;
Sarcoma of the cervix.
Syphilitic Ulceration.-Syphilitic ulceration of the cervix is a
very rare condition. Usually there is present condylomata.
This condition yields to proper treatment. The constitutional
manifestations of the disease are rarely wanting.
Areolar hyperplasia of the cervix and papillary erosion, with
ectropium, resemble carcinoma only at the beginning of the latter
634
A TEXT-BOOK OF GYNECOLOGY.
disease. If an immediate diagnosis is important the microscope
should be resorted to. If the chances are that the condition
is not malignant, proper treatment may be prescribed; this will
improve both areolar hyperplasia and papillary erosion. The
well-known test of Spiegelberg should also be applied. In carci-
noma there is, according to Spiegelberg, fixation of the mucous
membrane to the underlying indurated tissues; and rigidity of
the cervix. The last-named condition is indicated when an effort
is made to dilate the cervix by means of laminaria tents.
Sloughing Fibrous Polypus.-The tissues are firmer and do not
break down as easily as does carcinomatous tissue. The mass
is more sharply defined, because the surrounding structures are
less infiltrated.
Retention of the Products of Conception.-These lie loosely in
the cervical canal and are easily detached. It should not be
forgotten that carcinoma may make its first appearance during
the puerperium.
Sarcoma of the Cervix.-Sarcoma of the cervix is an exceed-
ingly rare condition. As in sarcomatous tumors in other parts
of the body, it grows more slowly than does carcinoma. It is
impossible to make a positive differentiation without resorting
to the microscope. Practically, the distinction between the
two affections is not important, for the treatment is the same in
both.
Progress of the Disease.—In cancer of the cervix the blad-
der is implicated in about 40 per cent. of all cases. It first
invades the cellular tissue between the bladder and the uterus,
finally attacking the mucous membrane. Fistulæ result in 20
per cent. of all cases. The ureters are still more frequently
disturbed. Complete obliteration of one or both ureters occurs
in 50 per cent. of all cases. Infiltration takes place, either at the
opening of the ureters into the bladder, or higher up at the sides
of the cervix. Occasionally the bladder, rectum, and vagina
are converted into a common cloaca. The peritoneal cavity is
rarely opened into. As the disease advances a protective lymph
is thrown out, and adhesions form between the peritoneum and
uterus. The extent and direction of the invasion are well
shown in Figs. 143, and 144.

MALIGNANT DISEASES OF THE UTERUS.
635
Prognosis. The prognosis, as regards life, will depend
largely upon the progress made by the disease when first de-
tected. During its early stage the general opinion is that
cancer is a local disease. If this opinion is correct, and judging
from the large number of operative cases now on record it is,
it means that cancer may be cured provided all of the diseased
FIG. 143.
MEDULLARY CANCER OF CERVIX INVADING THE VAGINA.
The cervix is entirely ulcerated away, and the bladder is also implicated. The
body of the uterus appears healthy, though the ovaries are adherent to it.
(Museum R. C. S. Photographed by the Author.)
tissue can be removed. So long, therefore, as it is confined to
the uterus, and does not involve the surrounding structures, it
is curable. Unfortunately, the surgeon does not meet with it
at this stage, except in a very small per cent. of cases. It will
take another decade to educate the general profession to the
importance of early diagnosis in carcinoma uteri.

636
A TEXT-BOOK OF GYNECOLOGY.
After the disease is no longer confined to the uterus the
prognosis is preeminently unfavorable.
Its duration is most variable-from six months to four or
five years. The average duration is two years; it will, how-
ever, depend upon the succeeding complications liable at any
time to arise.
Cause of Death.-Exhaustion is one of the most frequent
causes of death. It is due to hemorrhage, to leucorrhea, and
FIG. 144.
A UTERUS, THE CERVIX OF WHICH, TOGETHER WITH A PART OF THE VAGINA,
IS DESTROYED BY CANCEROUS ULCERATION.
The ovaries are slightly enlarged, and their surfaces are puckered. (Museum R. C. S.
Photographed by the Author.)
to the compromised and impaired nutrition. The last condition
is due to an inability to take food, as well as to the exceedingly
offensive odor almost never absent.
Uremia is the next most frequent cause of death. It results
from the occlusion of the ureters. Peritonitis occasionally ter-
minates life, though general peritonitis is of rare occurrence.
When it does occur as a complication, it is due to a sudden
giving way of adhesions, with consequent contamination of the
MALIGNANT DISEASES OF THE UTERUS.
637
peritoneal cavity. Hemorrhage, as has already been shown,
rarely, if ever, causes immediate death; the long-continued drain
will, however, greatly prostrate the patient and hasten fatal
exhaustion. Venous thrombosis may result in sudden death by
the formation of emboli, or it may give rise to phlegmasia
dolens. Finally, death may result simply from the absorption of
septic products derived from the breaking down of tissue.
CARCINOMA OF THE BODY OF THE UTERUS.
The statistics of Schroeder show that cancer is located in the
body of the uterus in less than two per cent. of all cases. The
observation of more modern writers is not in harmony with this
statement. It is probable that formerly many cases of carcinoma
of the body of the uterus were overlooked for the reason that
explorative dilatation and curetting were less frequently practised
than at the present time.
Pathology. The disease originates either in the mucous
membrane or in the uterine parenchyma. When it springs from
the mucous membrane it projects into the uterine cavity in the
form of a soft, friable mass; when it has its origin in the uterine
parenchyma, localized nodules project either toward the mucous
membrane or the peritoneal surface.
The various etiological factors enumerated under carcinoma
of the cervix apply to carcinoma of the body of the uterus,
except that the larger number of cases occur between the ages
of fifty and sixty instead of between forty and fifty. A much
larger per cent. of cases also occur in nulliparæ.
Symptoms.-Pain is a much earlier and more constant
symptom than is the case with carcinoma of the cervix. It is
severe, intermittent, and lancinating in character.
Hemorrhage is also a more prominent symptom than in car-
cinoma of the cervix. It is at first due to the increased
vascularity of the endometrium; later, it is caused by the break-
ing down of tissue. The characteristic cancerous discharge
follows necrosis of tissue. In time the cancerous cachexia
manifests itself.
Physical Signs.-The bimanual will show enlargement of the
uterus. There is more or less induration with tenderness on
•
638
A TEXT-BOOK OF GYNECOLOGY.
pressure. Unless implicated in the cancerous process, the
cervix is free from disease, although the os is often patulous.
The introduction of a uterine sound gives rise to hemorrhage.
Carcinoma of the body of the uterus will have to be distin-
guished from-
Retained portions of placenta and cystic degeneration of the
chorion;
Fungoid endometritis ;
Fibroid tumors and large fibrous polypi;
Sarcoma of the uterus.
As regards the first three conditions, pain is seldom severe;
the discharge, except in the first, is not offensive. Upon making
a microscopical examination of the products obtained by curet-
ting the evidences of malignancy are wanting.
Fibroid Tumors and Large Fibrous Polypi.-These growths
are more liable to be mistaken for carcinoma while undergoing
degeneration. There will be a history of menorrhagia long
continued. The uterine sound will show an increased depth of
the cavity of the uterus. Hemorrhage does not attend the
passing of the sound. If the cervix is dilated, the finger will
fail to detect the soft, fungoid, carcinomatous mass projecting
from the mucous membrane. Before the ulcerative process has
set in, it is extremely difficult to differentiate between carcinoma
springing from the substance of the uterus and fibroids. In
case of doubt the microscope should be resorted to.
The most expert microscopist cannot determine with absolute
certainty the presence or absence of malignancy by a micro-
scopical examination of curettings alone. The products removed
are often so insignificant that a simple glandular hypertrophy
attending endometritis may be distinguished with difficulty
from cancer. The whole depth of the uterine gland, or
glands, can rarely be obtained by curetting, and the diagnosis
will often have to rest upon probability rather than certainty.
Therefore, in those cases where the hemorrhage persists in spite
of repeated applications of the curette, as well as other recog-
nized therapeutic measures, and where the cause of the hemor-
rhage is evidently not disease of the uterine appendages, it may
be wise to resort to vaginal hysterectomy, particularly if the
MALIGNANT DISEASES OF THE UTERUS.
639
patient is approaching or passing through the so-called cancer-
ous age. I have removed the uterus in at least three cases for
persistent hemorrhages of this nature after an experienced
microscopist had failed to obtain from the curettings positive
evidences of cancer After its removal, the uterus showed
in each instance unmistakable evidences of malignancy.
Progress. As the disease progresses it frequently involves
the cervix and neighboring organs. Perforation occasionally
occurs into the peritoneal cavity, setting up peritonitis. Metas-
tasis to distant organs may also result.
Prognosis. If the condition is detected early the prognosis
is more favorable than in carcinoma of the cervix, for the reason
that there is less likelihood of the surrounding structures being
involved. If not interfered with, the prognosis is grave. Death
is due to the same causes enumerated under the head of cancer
of the cervix.
SARCOMA OF THE UTERUS.
Sarcoma, according to Cohnheim, is a connective-tissue tumor
of an embryonic type. Sarcomatous tumors were formerly
known as recurrent fibroids.
When met with in the uterus they occur in two forms: (1)
Diffuse sarcoma of the mucosa; (2) fibroid sarcomatous tumors.
Sarcoma is rarely located in the cervix.
Diffuse Sarcoma of the Mucosa.-The proliferation of
round or fusiform cells infiltrates the mucous membrane, and
gives rise to thickening. In time there appear “soft, villous, or
lobulated tumors, having an encephaloid aspect, and reproducing
an embryonic type of connective tissue." (Virchow.) These
fungoid masses are soft, irregular, and easily broken down. In
appearance they are grayish white. Deep excavation of the
mucous membrane does not occur, as in carcinoma. Sometimes
there are found mixed tumors composed of the histological
characteristics of carcinoma and sarcoma. A microscopical
examination of the mucous membrane will reveal masses infil-
trated with closely set round cells, with occasional spindle cells.
Fibroid Sarcomatous Tumors.-These growths, like benign
fibroid tumors, may be either interstitial, subperitoneal, or sub-
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A TEXT-BOOK OF GYNECOLOGY.
mucous. It is maintained by some authorities that they are
nothing more than malignant fibroid tumors. They arise in the
uterine parenchyma, but their isolating capsule is not distinct,
and they are deeply rooted. On section their consistence is soft
and homogeneous. Occasionally they undergo degeneration,
and are converted into muco-sarcoma or cysto-sarcoma.
Etiology.—While the larger number of cases occur at or near
the menopause, numerous instances of sarcoma of the uterus
have been met with in women under twenty years of age. Of
seventy-five cases analyzed by Gusserow, twenty-five were
childless, four of the twenty-five being virgins. This contrasts
markedly with carcinoma of the cervix and body of the uterus.
Symptoms. The symptoms of diffuse sarcoma of the mucosa
do not differ essentially from those of carcinoma of the body of
the uterus. There is an increase in the volume of the affected
organ. A serous discharge, alternating with hemorrhage more
or less profuse, is a frequent, though not a constant, symptom.
Cachexia is of later occurrence than in carcinoma of the uterus.
Pain is not an early symptom. There is also less fetidity of the
flow during the early period, and ulceration does not set in
until late.
In the beginning of fibroid sarcomatous tumors there is nothing
to distinguish them from benign fibroids. There is hemorrhage,
odorless hydrorrhea, some pain from pressure, and an increase
in the size of the uterus. After ulceration of the neoplasm
occurs, the hemorrhage becomes more profuse and the leucor-
rhea offensive. The discharge contains peculiar, rice-like masses,
which are broken down sarcomatous tissue. Inversion of the
uterus not infrequently results in consequence of sarcoma. There
is a complete fusion of the tumor with the contiguous tissues,
which makes enucleation impossible. Repeated recurrences after
removal are a peculiar feature of sarcoma. Metastatic deposits
have been found in the lungs, liver, vertebræ, and lymphatic
glands.
CHAPTER XLII.
MALIGNANT DISEASES OF THE UTERUS.-
(Continued.)
TREATMENT
If it be true that carcinoma is, at its beginning, a local affection,
becoming general only as it extends by contiguity of tissue,
or by the absorption of broken-down débris, the possibilities
of curing the disease depend entirely upon an early diagnosis
and early operative interference. This applies to carcin-
oma wherever located, but emphatically so to carcinoma
of the uterus, because with no other removable organ of the
body is it so difficult to reach beyond the parts primarily
affected. The surrounding glands cannot be enucleated; it is
only possible to remove a certain amount of tissue. That the
disease does, at the beginning, localize itself in the uterus, is, I
think, clearly proved by the large number of operative cases
now on record. Nevertheless, it is an unfortunate fact that at
least seventy-five per cent. of all cases of carcinoma and sarcoma
of the uterus will have passed beyond the operative stage before
coming under the observation of the specialist. The treatment,
then, naturally resolves itself into-
(a) Palliative;
(b) Curative.*
Palliative Treatment.-This will include the management of
the hemorrhage, the pain, and the leucorrheal discharge. The
hemorrhage can often be favorably influenced by the use of the
indicated remedy. I have but little faith in the action of
large doses of ergot for this purpose, especially when the
* In the treatment of the various malignant affections of the uterus, I have deemed
it best to consider under one head carcinoma and sarcoma of both the fundus and the
cervix. The same principles of treatment are applicable to the several forms of
malignancy, whether the disease is located in the body or the neck of the organ.
4I
641
642
A TEXT-BOOK OF GYNECOLOGY.
disease is limited to the cervix. If the indicated remedy is not
sufficient, and the hemorrhage is great enough to exhaust the
patient or to threaten her life, local medicaments must be used.
One of the least objectionable of these is the saturated solution of
alum; and the patient should always have at hand a sufficient
quantity of this agent to use whenever necessary. Cold water
may be resorted to for the same purpose. Should the hemor-
rhage still persist, a tampon, saturated with a weak solution of
perchlorid of iron may be placed against the bleeding surface.
To obtain the mechanical effects of the tampon, others must be
packed about it in such a way as to exert decided pressure upon
the cervix (v. p. 150). Should the hemorrhage proceed from the
body of the uterus, a solution of alum, heated, may be injected
into the cavity.
The nurse should be instructed as to the methods of con-
trolling hemorrhage, especially if the patient reside some
distance from the attending physician. The patient should be
advised to abstain from sexual intercourse and to observe care
in straining at stool. Indeed, constipation should always be
guarded against, for if the rectum is distended with hard fecal
matter it not only adds greatly to her distress, but predisposes
to hemorrhage.
After infiltration of tissue, pain becomes the most prominent
and most distressing symptom. When the disease is confined to
the cervix, much relief may be afforded by the local use of anes-
thetic and narcotic agents. Iodoform is not only a powerful disin-
fectant, but it is also a local anesthetic of much value. It may
be applied directly to the parts by means of a powder blower;
or it may be mixed with almond oil (13–31) and applied by
means of a tampon. The fluid extract of opium, either in the
form of suppositories or applied directly to the ulcerated sur-
face, is beneficial. The fluid extract of belladonna is also a use-
ful agent, particularly if the pain is of a throbbing character.
Suppositories composed of one grain of the fluid extract of
opium and one-quarter of a grain of the fluid extract of bella-
donna is an old and well-tried method of using these agents com-
bined. Equal parts of chloroform, glycerin, and sweet oil is
another old formula and at times a most useful one. (Ludlam.)
TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 643
This preparation may be applied by means of a tampon. A
solution of hamamelis, or a saturated solution of hydrate of
chloral, may afford relief when other remedies fail or their effect
becomes exhausted.
In contending with pain, invaluable service may be obtained
from the properly selected remedy. The physician is urged to
withhold the internal administration of opium as long as it is
possible to do so without permitting his patient to suffer too
greatly. It is even claimed by some of the best men in the
homeopathic school that the use of opium is never necessary in
contending with pain of any kind. I cannot refrain from con-
gratulating the prescriber who is sufficiently skilled to dispense
with the use of this agent in the disease under consideration.
No one deprecates more than I the internal administration of
opium, especially in cancer. I am nevertheless compelled to
admit that during its later stages I am many times unable to
control the almost intolerable suffering incident to it without
resorting to some of the forms of opium. Its use is attended
with unpleasant consequences which I should be only too glad
to avoid. These consequences are, however, in my opinion,
more than offset by the relief afforded. The disease, after
reaching a certain stage, is inevitably fatal, and it has always
seemed to me that it is the duty of the physician to bring to
its victim all possible means of relief. If he cannot keep her
comfortable without the use of opium, I believe he should
administer it in doses sufficiently large to accomplish the desired
end. However, the drug should not be given until it is abso-
lutely necessary; it quickly exhausts itself and will have to be
repeated in ever-increasing doses until the amount required is
sometimes enormous. It is best administered hypodermatically.
The leucorrheal discharge is to be contended against by the
frequent use of antiseptic and disinfecting fluids. Of these a
solution of permanganate of potash is one of the best. It should
be used as a douche (20: 1000), and repeated as often as neces-
sary. After the parts are cleansed with this solution, an iodo-
form suppository containing two grains of iodoform may be
introduced into the vagina. Carbolic acid (one to fifty) is
also a powerful disinfectant, and possesses anesthetic proper-
644
A TEXT-BOOK OF GYNECOLOGY.
ties as well. A solution of thymol (five per cent.) or bi-
chlorid of mercury (1:5000) may also be used for this pur-
pose. Hot water alone, administered in large quantities, will
not only cleanse the parts, but will many times greatly relieve
the suffering (v. Chapter X).
Erythema of the vulva, during the later stages of cancer
is often most distressing. The parts should be protected by
some of the ointments recommended for pruritus vulvæ. Equal
parts of olive oil and lime-water applied to the vulva will often
afford marked relief. A solution of chlorinate of soda is also
highly recommended by some writers.
A more formidable palliative measure, which is surgical in
its nature, is curetting. It is especially useful in those cases
where the disease is made up of soft, friable masses projecting
either into the uterine cavity or from the cervix. The hemor-
rhage, the offensive discharge, and the pain, are largely due to
these papillomatous growths. If removed by the curette, the
relief afforded is often most marked. The hemorrhage is tem-
porarily controlled, the offensive discharge ceases for a greater or
less length of time, and the pain is most decidedly ameliorated.
Moreover, the symptoms of sepsis, due to the absorption of
necrosed tissue, will disappear for the time being. As a pallia-
tive measure, then, the use of the curette is of the first impor-
tance.
In most instances I deem it best to place the patient under
the influence of an anesthetic before the curette is applied.
There should be at hand the various preparations of iron for the
purpose of controlling hemorrhage, as well as a Paquelin cautery.
After the speculum is introduced, the cervix is supported by
the volsella, and Simon's sharp spoon curette is expeditiously
but thoroughly applied, all of the necrosed tissue being scraped
A stream of hot bichlorid should be kept playing upon
the parts during the operation, as the hemorrhage is usually very
profuse. The raw surface is now seared over with the Paquelin
cautery. Ordinarily, this will control the hemorrhage; if not,
a solution of perchlorid of iron may be applied. A strip of
iodoform gauze is finally carried into the uterus if the case is
one of carcinoma of the body, or packed into and about the
away.
TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 645
cervix if the disease is limited to the neck. Additional strips
of gauze are packed into the vagina. These can be left in for
two or three days, after which they are removed and the parts
kept thoroughly clean by antiseptic and disinfecting injections.
Besides the various local measures which have been enume-
rated, it is important to maintain the nutrition of the patient by
nourishing food and by proper hygiene. Owing to the offensive
discharge, the sick-room should be kept thoroughly ventilated;
if the patient can have at her command two rooms, so that one
can be aired while she is occupying the other, such an arrange-
ment will be advantageous.
It seems unwise to inform the patient that she is the victim of
incurable malignant disease, unless it is absolutely necessary
because of business affairs, to do so. If the facts are known to her
the effect upon the mind is most distressing. Since she is liable.
to live for months, or even for years, there is no reason why she
should be informed of the inevitable end. Of course her
immediate friends should be made familiar with the diagnosis
and prognosis-this for the physician's protection. Again, it is
never wise to prophesy too closely as to the probable duration
of life. The physician can only state the average duration of
the disease, at the same time emphasizing the fact that certain
complications may suddenly terminate life.
Therapeutics.
Arsenicum alb.-Cancer of the uterus, with burning, agoniz-
ing pain, and secretion of fetid, brown or blackish ichor; faint-
ness; BURNING PAINS, even felt while sleeping; ACRID AND
CORRODING LEUCORRHEA; emaciation, with excessive debility;
restlessness; symptoms of septicemia.*
Hydrastis Can.-Ulceration of cervix and vagina, with sym-
pathetic affections of the digestive organs; the discharge is tena-
cious, thick, and ropy; pruritus vulva, with sexual excitement.
Conium mac.-HARDNESS OF UTERUS, WITH INTOLERABLE
LANCINATING PAINS THROUGH THE PELVIS; acrid, burning leucor-
rhea, preceded by pinching pains in abdomen; carcinoma
form.
*If the induration and hardness are marked, Arsenicum iod. is the preferable
646
A TEXT-BOOK OF GYNECOLOGY.
following chronic inflammation and induration of ovaries; scanty
menstruation, especially in sterile women.
Kali bich.-Leucorrhea yellow and ropy, with pain and
weakness across small of back; dull, heavy pains in hypogas-
trium.
Phytolacca. Menses too frequent and too copious; metror-
rhagia; ropy leucorrhea toward morning; hunger soon after
eating; urine dark-red, with painful micturition.
Thuja.-CAULIFLOWER EXCRESCENCE PROJECTING FROM CERVIX;
erosions of os uteri; aphthæ.
Graphites.-Violent lancinating, stitching pains through the
uterus down to the lower extremities; inclined to obesity, with
a history of delayed menstruation; swelling of the feet; the
discharge is glutinous, or watery; itching blotches on various
parts of the body.
Kreosotum.-Burning sensitiveness and tumefaction of the
cervix with bloody ichorous discharge; the genital tract is sensi-
tive to touch and to coitus; great putridity of discharges.
Belladonna.—Bearing doWN SENSATION as if the INTERNAL
ORGANS WOULD ESCAPE EXTERNALLY; pains are of a shooting,
tearing character, coming on suddenly and finally leaving as
suddenly; hemorrhage profuse and offensive; the parts feel dry
and hot internally.
China. Especially useful to overcome the effects of the long-
continued hemorrhage and leucorrhea; the patient is worse
every other day; flatulency, which is not relieved by the discharge
of flatus.
Lachesis.—Cancer occurring in women approaching or pass-
ing through the menopause; frequent hemorrhages; FLUSHES OF
HEAT; the pain is sometimes very violent, as if a knife were
thrust through the abdomen.
Consult:-Phosphorus, rhus tox., sepia, sulphur, murex pur.,
secale, tarantula, trillium, and zincum met.
Curative Treatment.-This has practically resolved itself
into one measure, viz., Vaginal hysterectomy. Supra-vaginal
amputation of the cervix, as practised by Verneuil, Schroeder
and others, still has its advocates; but since vaginal hyster-
TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 647
ectomy has become a popular operation, comparatively few
surgeons perform supra-vaginal hysterectomy, even though
the disease is apparently limited to the cervix. Indeed, vaginal
hysterectomy is not essentially more formidable than is the incom-
plete operation, and by it both hemostasis and antisepsis are more
easily attained. It is utterly impossible to determine, in a given
case of cancer of the cervix, whether or not the disease is limited
to the cervical portion of the uterus. It is a well-known fact
that, in the majority of instances, it is not so limited; conse-
quently, the broad principle of extensive ablation which applies
to carcinoma of other parts of the body, applies with double
force here. It is true that it is not always possible to de-
termine, previously to the removal of the uterus, whether or
not the disease is limited to this organ. This fact is forced
upon us by the return of the disease in a certain per cent. of
cases after total extirpation. It must not be forgotten that
vaginal hysterectomy is a comparatively recent operation. Un-
questionably many uteri have been removed per vaginam that
ought to have been left alone. The operation is justifiable under
certain conditions only; these conditions should prevail before
it is attempted.
Indications and Counter-indications for Vaginal Hyster-
ectomy.-Vaginal hysterectomy is indicated when the disease
implicates the fundus, and the uterus is yet mobile; and when no
evidences of its invasion beyond the uterus can be obtained by
careful examination. I do not believe that the surgeon is justified
in operating if the vagina is even slightly involved at its fornices,
if the uterus is fixed, or if large glands can be detected in the folds
of the broad ligaments, or extend along the utero-sacral ligaments.
A most careful examination should, therefore, always precede
the operation. Much information can be obtained by the bi-
manual, if embarrassing obstacles do not exist. The cervix
should be drawn down with the volsella and an exploration
made through the rectum. In case of doubt, a more extended
examination should be made under an anesthetic.
Operation. The patient should be prepared for the operation
as for abdominal section. The bowels, and especially the rectum,
should be thoroughly emptied, and the vagina carefully disinfec-
648
A TEXT-BOOK OF GYNECOLOGY.
ted. Antisepsis of the vagina is secured by frequent douching with
a 1: 3000 bichlorid solution. A preliminary curetting, where
the papillomatous masses are abundant, is advisable. Unless this
precaution be taken there is danger of infecting the peritoneum
with the cancerous discharge during the operation. The curet-
ting should be done four or five days before the hysterectomy
is performed.
After the patient is anesthetized she should be placed before
a good side light in the lithotomy posture. The Fritsch specula
are preferable to the Sims, the superior blade permitting of
continuous irrigation. Lateral retractors (Fig. 145) are also
necessary.
A final washing of the vagina is resorted to, when the cervix
is seized with strong volsella and carried forward. The bladder
FIG. 145.

G.TIEMANN & CO.
SIMONS' RETRACTOR.
is located by introducing a sound through the urethra, and
sweeping it over the anterior portion of the cervix. An incision
is then made with a scalpel through the mucous membrane
above the diseased area, completely encircling the cervix. The
scalpel is now discarded and further dissection is made with
blunt, curved scissors, or with the fingers. The dissection is
extended posteriorly toward the Douglas cul-de-sac, which is
opened into, and then enlarged with the fingers or with a
dilating instrument (Sims's uterine dilator is very useful for this
purpose). Two fingers of the left hand are next introduced
through the opening thus made and, guided by the posterior
layers of one of the broad ligaments, are carried over the liga-
ment and into the utero-vesical pouch. The fingers will serve as a
TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 649
guide for opening into this pouch, the mucous membrane in front
of the cervix having been dissected up as far as the peritoneum.
Some difficulty may be experienced in tearing the tense perito-
neum with the finger; this may be overcome by using a pair of
sharp-pointed dressing-forceps, which are introduced, expanded,
and then withdrawn. The tissues are separated laterally as far as
the base of the broad ligament on either side.
The broad ligaments may be secured either with forceps or with
ligatures. Unquestionably, the forceps is the easier and more
expeditious way of securing them. Their use, however, is not
without certain objections that do not apply to the ligature; there
is greater danger of sepsis as well as obstruction of the bowel.
Forceps devised especially for the purpose and long enough to
include the entire broad ligament in its blades (Fig. 146) may be
FIG. 146.

ETLEMANN & CO.
LEE'S MODIFICATION OF GREIG SMITH'S BROAD LIGAMENT CLAMP.
applied, or several smaller ones may be substituted for the special
instrument. When the smaller ones are used, it will be neces-
sary to apply the first pair to the lower border of the broad liga-
ment, incise to a depth corresponding to the blade of the instru-
ment, and then apply the second pair above the first, and repeat
this procedure until the entire ligament is secured and severed.
I have left ten or twelve pair of forceps within the vagina when
used in this way. The broad ligament on one side is first dealt
with in the manner described, after which the second one can be
secured with much less difficulty. After the uterus is cut away
the edges of the wound are brought together between the for-
ceps on either side with one or two sutures; the peritoneum is
included in these sutures. The vagina is again thoroughly
650
A TEXT-BOOK OF GYNECOLOGY.
washed with a 1 : 5000 bichlorid solution; iodoform gauze is then
loosely packed about the forceps in the vagina. The forceps,
which are left behind for from twenty-four to forty-eight hours,
afford sufficient drainage, and, as a rule, little or no hemorrhage
follows their removal (Péan).
When the ligature is used, according to Leopold's method,
a special instrument devised for the purpose is necessary (Fig.
147). After the mucous membrane has been dissected from the
cervix to the bases of the broad ligaments, the first ligature is
introduced about three-quarters of an inch from the lower border
of one of the ligaments. In order to avoid the ureters, it should
be placed as near the cervix as is possible without including
diseased tissue. This ligature will ordinarily secure the uterine
artery. After one is placed on either side, the ligament can be
incised nearly to its upper border. A second ligature is placed
above the first, and the broad ligament again divided for a suffi-
FIG. 147.

GTIEMANI
THE AUTHOR'S NEEDLE FOR VAGINAL HYSTERECTOMY.
cient depth. This process is repeated until both ligaments are
secured, and the uterus detached and removed.
It is, I think, a good plan when the broad ligaments are
secured by ligature to introduce at least one or two sutures in
such a way as to bring both edges of the wound together at its
middle. Some operators recommend stitching the stumps of
the broad ligaments in the wound. I can see no special advan-
tage in doing this.
The question of drainage will be decided by the predilections
of the operator. Personally, I think it best when the forceps
are not used to secure drainage for at least three or four days.
This can be done by introducing a glass tube through the
wound and packing about it iodoform gauze; or a strip of iodo-
form gauze may be passed into the wound and left behind for
from three to six days. I do not deem it wise to leave the
TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 651
wound entirely open, as is recommended by some operators. In
one of my cases where this was done, the intestines came
down into the vagina when the gauze was removed. After
the removal of the gauze the vagina should be kept clean
by frequent irrigation with a 1:5000 bichlorid solution. Care
must be taken that none of the antiseptic fluid passes into the
peritoneal cavity.
Whether the appendages should be removed with the uterus will
depend upon circumstances. If the ovaries and tubes are easily
accessible, I think it best to remove them. If, on the other
hand, the operation will be made much more difficult by their
removal, it is best to leave them behind. Their presence will
give rise to but little trouble, even though the patient has not
ceased to menstruate. Indeed, it is recommended by one
operator (Thornton) that the ovaries be left behind for the pur-
pose of preventing premature climacteric changes.
The after-treatment does not differ from that recommended for
abdominal section. The patient should be kept in bed for at
least two weeks, and prevented from undue exertion for some
time longer. The same complications liable to arise after lapar-
otomy may follow vaginal hysterectomy, and, if they do occur,
should be dealt with in the same way.
Accidents.-Injury to the ureters is the most frequent acci-
dent. This is best prevented by hugging the cervix as closely as
possible during the operation. It is announced by the ordinary
symptoms of uremia, or by the formation of a uretero-vaginal
fistula. The bladder is likewise occasionally injured. If opened
into during the operation, it should be closed at once by silk
sutures. A still rarer accident is perforation of the rectum.
This, however, will not happen unless the operator is exceedingly
careless.
When death occurs, it may be due to hemorrhage, shock,
septicemia, peritonitis, or intestinal obstruction. Death from
hemorrhage was very much more frequent before the technique
of securing the broad ligaments was fully mastered. Shock may
be due either to the loss of blood, or to the difficulties attend-
ing the operation. It is much less severe in short operations than
in operations requiring a long time for their completion.
652
A TEXT-BOOK OF GYNECOLOGY.
The Results of Vaginal Hysterectomy.-In considering the
results of vaginal hysterectomy, it is no more than right that the
statistics should be based upon the experience of specialists who
have performed the operation many times. I can do no better
than quote the tables furnished by Pozzi. The first comprises
the experience of four German gynecologists up to the end
of 1886, and is as follows:-
Recurrence at the end Leopold, out
•
of-
I year,
1½ years,
of 36 Opera-
tions.
Schroeder, out
of be Opera-
tions.
17
Fritsch, out of 53 Martin, out of 56
Operations.
Operations.
16
20
35
9
IO
17
32
5
7
7
25
3 years,
2
4
2
20
4 years,
2
•
4
2
25
5 years,
2
4
2
3
6 years,
2
4
2
2
2 years,
"These figures give the following percentages: Recurrence at
the end of one year, 42.30 per 100; one and a half years, 32.90;
two years, 21.15; three years, 13.41; four years 2.40.”*
A still more important series is that of Leopold's. Out of
eighty vaginal hysterectomies for cancer made by this specialist,
only four succumbed to the operation. I again quote from Pozzi†
to show the final results of the seventy-six patients that recovered.
Out of seventy-six patients re-examined after recovery there
remain, without recurrence:
5½ years,
54 years,
44 years,
334 years,
3½ years,
•
•
•
.1 3
222
•
6
years,
234 years,
2½ years,
214 years,
2 years,
3
•
3
4+
•
Between I year and
2
1½ years,
•
3
114 years,
2
2
3 months,
•
3
I do not believe that these statistics, notwithstanding the fact
that they are based upon the results obtained by some of the
most celebrated operators, fairly represent the per cent. of cures
possible under more favorable conditions. Undoubtedly, many
of the operations included in the figures given were made upon
* Pozzi, “A System of Gynecology," p. 237.
† Ibid, p. 238.
In dealing with a disease inevitably fatal, as is carcinoma of the uterus if un-
molested, a radical cure of twenty-five per cent. only of all cases operated upon must
be considered successful.
TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 653
inoperative cases. It seems to me utterly useless to resort to
vaginal hysterectomy after the disease has extended beyond the
uterus, implicating the vaginal tissue and the structures within
the pelvis. If the cases are properly selected, the results ob-
tained are certainly most satisfactory. The average immediate
mortality following vaginal hysterectomy should not be greater
than ten per cent. ; and, as we have seen by the statistics of Leo-
pold, it may be reduced as low as four per cent.* The same
objection cannot, therefore, apply to vaginal hysterectomy that
applied to the older abdominal operation of Freund, with its
frightful mortality of 75 per cent.
Modifications of the Operation.-If there is difficulty in
securing the broad ligaments, the uterus may be inverted by
grasping its fundus through the posterior cul-de-sac with a pair of
volsella forceps and drawing it down into the vagina. This will
twist the broad ligaments in such a way as to make them much
more easily gotten at. It may be necessary to incise the perineum
in order to obtain sufficient room to work within the vagina.
Martin stitches the peritoneum to the mucous membrane of the
vagina, both in front and behind, with interrupted sutures. Fritsch
begins his dissection at the lateral fornices and secures the
uterine arteries as the first step in the operation. Schatz does
not detach the bladder until the last step of the dissection.
Olshausen guards against infection of the peritoneum by defer-
ring the opening of the cul-de-sac as long as possible. Müller
seeks to control the hemorrhage by pressure upon the abdominal
aorta. Sanger recommends the thermo-cautery for dividing
the vaginal cul-de-sac. Fritsch and Czerny turn the uterus for-
ward instead of backward. Montgomery passes a large sponge,
to which is attached a tape, into the posterior cul-de-sac as soon
as it is opened, so as to keep the intestines back and prevent
blood from entering the peritoneal cavity. Otto Zuckerkandl
makes a transverse incision, between the ischiatic tuberosities,
through the perineum so as to increase the space at the ostium
vaginæ. It may be necessary to resort to one or more of these
modifications in a given case. (Pozzi.)
* Doctors Lee and Pratt, of this country, have now reduced their mortality in vaginal
hysterectomy to less than four per cent.
654
A TEXT-BOOK OF GYNECOLOGY.
Wolfler and Zuckerkandl practise parasacral and pararectal
incision when it is impossible to remove the uterus through the
vagina. Kraske extirpates not only the coccyx but the inferior
part of the sacrum as well, thus creating a large opening through
which the cancerous uterus can be removed. Hegar, instead of
removing the coccyx and a portion of the sacrum, depresses them
after severing their lateral attachments. The bones are replaced
after the hysterectomy is completed. These operations are nec-
essary only when the uterus is so large as to make it impossible to
remove it through the vagina. It is exactly this condition which,
in ninety-nine cases out of a hundred, is associated with in-
fection of the periuterine structures—hence any form of hys-
terectomy is counter-indicated. I allude to them for the sake of
completeness only.
Dr. Pratt's new method of performing vaginal hysterectomy
is now receiving much and favorable attention. I have seen
Dr. Pratt make his operation but once, and that was in a
most unfavorable case of cancer of the cervix-a case which
seemed to me (I did not make a physical examination) too far
advanced for any kind of a radical operation. Those who have
seen Dr. Pratt operate in suitable cases describe his technique as
being most ingenious. I have the impression, nevertheless, that
however well-adapted it may be to hysterectomy for non-malig-
nant diseases of the uterus, it is not the best method of remov-
ing cancerous uteri. The broad principle of extensive ablation
can hardly be observed by hugging the uterus in the process of
dissection. I deem it but just to Dr. Pratt to give his own de-
scription of the operation, which is as follows: *-
The uterus is first dilated and packed with antiseptically-prepared candle-wicking,
to render it firm and easily distinguishable from surrounding tissues. The very tip of
the cervix is then seized by a small double vulsellum or transfixed by guy ropes, and,
while an assistant is drawing the uterus downward to its easy possibilities, the mucous
membrane covering the outer surface of the cervix is amputated with a pair of sharp
scissors, curved at the tip, as close to the end of the cervix as is practicable, the cut
being made completely around the cervix. A spud is then employed to skin the mem-
brane of the cervix from below upward as far as the ligamentous fixation of the uterus
at the junction of the neck and body. The dissection should progress evenly around
the entire circumference of the cervix, as this permits the symmetrical descent of the
* Medical Century, November, 1893.
TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 655
uterus and brings the entire field of operation easily within view. The ligamentous
attachments at the upper end of the cervix are to be completely exposed by a spud,
and from this point onward the dissection must be made either with tenaculum and
scissors, or with a sickle-knife, such as I have devised for this work. Where the vagina
is sufficiently copious the thumb and finger of either hand may displace the tenaculum,
and, where these can be employed, are superior to it, as they aid in discriminating
the boundary line between the uterus and the surrounding tissues. By cutting all
ligamentous attachments close to the surface of the uterus it is possible to avoid the
wounding of any large-sized blood-vessels. The dissection is to be carried on evenly
around the circumference of the uterus until it reaches in front the point where the
peritoneum is reflected from the anterior surface of the uterus upon the posterior sur-
face of the bladder, and at the back where the peritoneum is reflected from the poste-
rior surface of the uterus upon the anterior surface of the rectum. At these places
the peritoneum is to be seized with a tenaculum and snipped with scissors, the open-
ings to be enlarged by divulsion, either with a pair of forceps or with the fingers,
until the wound extends on either side to the lateral margins of the uterus. The
finger can now be introduced into the peritoneal cavity at the posterior opening,
and by flexing it the lower part of the broad ligament and its contents can be
brought into easy view, the assistant, by traction upon the guy ropes or vulsellum,
drawing the uterus, to the opposite side. The dissection can now progress on one
side of the uterus by the aid of scissors or the hysterectomy knife, until the uterus
descends sufficiently to permit the operator to curve his finger around the upper
margin of the broad ligament, after which the dissection can be continued until the
attachments of the broad ligament at one side of the uterus are entirely severed.
In making this dissection the uterine artery is usually observed pursuing its tortu-
ous course upward between the folds of the broad ligament. It bulges into the wound
so plainly, and its pulsation can be so easily detected, that it often serves as a land-
mark in the dissection, although the only safe rule is to adhere to the proposition that
the dissection must constantly hug the uterine tissue, a diversion from this rule to the
extent of the sixteenth or even thirty-second part of an inch being often followed by
profuse hemorrhage.
Before completely severing the broad ligament, it is well to seize one or both of its
margins with a pair of T-forceps, so as to place the margins of the peritoneum en-
tirely at the command of the operator. With a double vulsellum the side of the
uterus which has been liberated by the dissection is now to be seized and dragged
downward. The forefinger of the operator is to be placed back of the remaining broad
ligament, and the tissues severed either from below upward or above downward, as is
most convenient, care being taken as before to secure control of the margins of the
broad ligament by T-forceps before the dissection is completed.
When the uterus is removed, upon examination it will be readily seen that the
anterior and posterior surfaces of the body of the organ are covered by the perito-
neum, and that only on the side has the dissection proceeded as far as the fundus.
This dissection will have the appearance of a V, with its apex at the fundus and its
base at the lower part of the body of the uterus. The uterus itself has not been
wounded.
Several times I have made this dissection with the loss of not more than one or
two teaspoonfuls of blood. In perhaps a majority of the cases (and I have now
operated upon forty-seven), it has not been necessary to use an artery forceps during
656
A TEXT-BOOK OF GYNECOLOGY.
the entire operation. Quite frequently, however, from not following the rule, and
from omitting to hug the uterus closely enough in the dissection, artery forceps will
be needed and a ligature called for. In very exceptional cases several ligatures will
be required before the completion of the dissection. The loss of blood, however,
need never be excessive, as the field of operation is always well-exposed, and at the
command of the operator.
The T-forceps, which were fastened upon the margins of the broad ligaments, are
now to be seized one at a time, and traction employed to bring the ovaries and Fallo-
pian tubes into view. This can be done in a majority of cases, when they can
easily be removed, and the peritoneal wound thus made can be closed by a continu-
ous catgut suture. If, in removing the tubes and ovaries, the dissection be carried
close to the organs, it is usually a bloodless procedure. Occasionally, however, adhe-
sions will prevent the ovaries from being brought into view, in which case they can
be either carefully loosened from their attachments by the finger or a blunt scoop, or
may be left unmolested, at the discretion of the operator. In only three cases thus
far in my experience have I been unable to remove the ovaries and tubes in this
manner.
The margin of the wounded peritoneum is now to be seized around its entire cir-
cumference by T-forceps and brought well into view. Beginning posteriorly, its edges
are to be carefully coaptated by a continuous catgut suture, after which, while the
wounded surface of the vagina is held apart by T-forceps, a plug of absorbent cotton
wrapped in antiseptically-prepared silk, and sufficiently large to entirely fill the open-
ings at the upper extremity of the vagina, is introduced into the wound. The lower
part of the vagina is then packed with iodoform gauze, and the operation is complete.
Occasionally, where the cervix has been pretty thoroughly destroyed by cancerous
degeneration, and where the tissues of the upper part of the cervix have been so rein-
forced by inflammatory products as to retain the uterus too high in the pelvis to ren-
der the dissection an easy one, after the peritoneal cavity is entered, the fundus of the
uterus may be drawn down into the vagina either forward or backward, as is most
easily accomplished, and seized by a double vulsellum. This can be accomplished
by "climbing” upon its surface with tenacula, employing two or three of them, and
inserting them one by one, each a little higher than the other, in the body of the
uterus until the fundus is reached and dragged down. As soon as the fundus is made
to appear in the vagina it is seized by a double vulsellum, and, while the assistant is
using traction upon it, the attachments of the broad ligament to the uterus can be
severed from above downward, the same care being exercised to confine the dissection
closely to the body of the uterus.
Of the forty-seven cases which I have operated upon, nineteen were for cancers,
several of them so far advanced in the destructive process as to have rendered removal
by means of clamps or ligatures so difficult that I think it would have been impossible
for me to have applied these methods, although it would not be modest for me
to say that other operators could not. In one case the bladder was involved to
such an extent that it ruptured easily in the early part of the operation, the cancerous
process having invaded this organ. In another this was true of the rectum. In
several the cervix was entirely gone and the operation could not be performed from
below upward, and the peritoneum had to be entered and the work accomplished
from above downward. Two of the cases were fibroid tumors, weighing two
and a half pounds respectively. Several of the cases presented quite a number
TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 657
of small extra-uterine fibroids, others several small intramural fibroids, and two or
three of them intra-uterine fibroids. Four were for reflex troubles, where the removal
of the ovaries some years previously had brought no benefit, but the removal of the
uterus was satisfactory. Twenty were cases in which an exploratory entrance into
the peritoneal cavity between the uterus and bladder disclosed ovaries and tubes in
such a degree of degeneration as to demand removal. Where the ovaries and tubes
require removal it seems to me an untimely proceeding to do so and permit the uterus
to remain unmolested, as it is now an almost universally accepted theory that ovarian
troubles have their beginnings in pathological conditions of the endometrium, and it
is my practice where it is necessary to sacrifice the ovaries and tubes, to remove the
uterus also. In several of the cases there was pelvic cellulitis, and the dissection
opened abscess cavities which bathed the parts freely in pus. In several cases the
ovaries were simply large abscesses, and in a few the tubes were enlarged and filled
with pus. Four were for procidentia. Of course, there has been no wounding of
the ureters, as this method of operating renders this accident entirely uncalled for.
Not a single case has developed even the slightest degree of peritonitis. There have
been no secondary hemorrhages but one, ending in death. In the forty-first case a
uterine artery was accidentally wounded and ligatured with catgut. In all probability
the ligature was not well applied, as an hour later, while I was engaged in operating
upon another case, during a retching spell the patient experienced an excessive
hemorrhage, and before it could be checked this had so depleted the patient that she
succumbed the evening of the same day. I am free to confess that this accident
should not have happened, and it is with deep regret that I am compelled to chronicle
this single break in an otherwise perfect record, in so far as recoveries are concerned.
The fatal case was not a difficult one to operate upon, but the patient was hemorrhagic
and her arterial coats were degenerated so as to be quite brittle. Perhaps instead of
slipping the ligature the artery broke off during the strain upon it when she vomited.
Illustrative Cases.
I have selected three cases of vaginal hysterectomy from my
own case-book, for the purpose of showing the special difficulties
and complications liable to arise. The two cases of fistulaæ-
rectal and vesical-show their tendency to spontaneous closure.
if properly cared for.
CASE LXXII.-Diffuse Sarcoma of the Mucous Membrane of the Uterus of Over
Two Years' Standing. No Tangible Infiltration of the Broad Ligaments, Bladder,
Vagina, or Rectum. Total Extirpation of the Uterus and Left Ovary. Opening
into the Rectum. Recovery.* Mrs. L., æt. 52, of Cohoctah, Livingston County,
Michigan. She presented herself at my clinic January 5, 1887. Her mother is
living, aged sixty-nine years, and has always enjoyed the best of health, having a
perfect family history. Her father died twenty-one years ago at the age of sixty,
death being caused by some form of ulceration of the leg, which had existed for
thirty years and which was supposed to be the sequela of mercurialization. Her father's
* Transactions of the Homeopathic Medical Society of the State of Ohio, 1887.
42
658
A TEXT-BOOK OF GYNECOLOGY.
sister had a similar sore which, during a period of twenty years, made its appearance
at variable intervals. The patient has been married for thirty-four years, having
borne six children at term and having had one miscarriage. The oldest child, a
son, is thirty-two years of age; the youngest twelve. The miscarriage occurred three
years after the birth of the last child. Her labors were always difficult, and at the
last confinement the placenta was adhered and had to be forcibly removed. She did
not get up well from this labor, and afterwards was troubled with prolapse of the
uterus, the cervix at times presenting externally.
She began to menstruate at sixteen, and up to the birth of her last child the
menses were normal in quantity, quality, and duration. During the last twelve
years, however, this function has been painful, the discharge being usually watery or
light colored, though at times dark red or green.
Two weeks before the miscarriage she suffered from an attack resembling peritonitis
and flowed excessively before the fetus was expelled. From this time on menorrhagia
and metrorrhagia became prominent symptoms, and her attending physician, attribut-
ing the unnatural flow to local congestion, endeavored to check it by scarifying the
cervix.
This treatment proving ineffectual, he dilated the cervix and explored the uterine
cavity with the finger, finding, in the language of the patient, "a mass," which he
failed to remove after repeated efforts.
Three weeks later medicated uterine injections were resorted to, which temporarily
controlled the hemorrhage. In a few weeks the discharge recurred, and with it
were pieces varying in length from one to three inches, which (again to use the
language of the patient) "resembled chicken-lights." These pieces continued
to pass for about six weeks, when they disappeared and did not recur until two years
ago.
Meanwhile, the floodings recurred at intervals varying from one to three months,
and lasted from one to four weeks. These attacks were accompanied with an intense
neuralgic-like pain in the abdomen.
Two years ago she suffered from an unusually severe attack of this character, which
was followed by metrorrhagia, continuing four months. The discharge was thin,
watery, unoffensive and not unlike the washings of fresh meat. Since last Septem-
ber she has flowed continuously, shreds of membrane at all times being present in
the discharge.
The patient had, upon entering the hospital, a decidedly cachectic appearence, but
the cachexia more closely resembled that of anemia than malignancy. Although
weighing one hundred and sixty pounds, her flesh was soft and unnatural.
A local examination made on the above date, revealed the following condition :
The uterus was enlarged and prolapsed; the cervix was greatly hypertrophied; the
os was dilated and gaping; the cervix was badly lacerated and contained much cica-
tricial tissue; both vaginal walls had descended with the uterus, causing a cystocele
and a rectocele; the perineum had been torn down to the sphincter vaginæ, and the
ostium vaginæ was greatly dilated.
The uterus was so heavy that I could not, or rather did not dare, reposit it with the
sound. With the aid of the volsella, however, the organ could be dragged down-
ward far enough to expose the cervix externally, showing that there could be no
adhesions of the fundus. I could discover no nodules involving periuterine cellular
tissue; nor was there any evidence of involvement of the bladder or rectum.
TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 659
Under chloroform a sufficient amount of tissue was removed, with the curette, to
make an examination. Macroscopically, this resembled pieces of membrane not
altogether unlike scrapings of fresh meat; microscopically, the closely set round cells,
with an occasional spindle cell, pointed unmistakably to sarcoma.
January 22, 1887, the patient was again brought under the influence of an anes-
thetic, and the cervix dilated sufficiently to admit the index finger.
The whole endometrium was found to be in a degenerated condition, the uterine
cavity being filled with a soft, friable mass springing from it. With Simon's spoon-
curette I removed the diseased tissue as thoroughly and completely as possible,
afterwards washing the cavity with a two per cent. carbolized solution. Churchill's
iodin was then applied to the entire raw surface, a glycerin tampon introduced, and
the patient placed in bed.
The usual precautions were observed to guard against peritonitis, but the operation
was followed by an attack which was more or less diffuse, the temperature reaching
104°. There was at least two ounces of the morbid tissue removed, which was of
a grayish-white color, soft and pulpy in consistence.
By February 2d the inflammatory symptoms had subsided, though there was a pro-
fuse and somewhat offensive discharge of pus from the uterus, the cervix remaining
dilated.
After thoroughly cleansing the cavity another application of iodin was made,
which temporarily improved her condition in every way. At the end of three weeks,
however, the unfavorable symptoms returned, when vaginal hysterectomy was decided
upon. This was done on March 7, 1887, in the presence of the senior and junior
classes of the college, and Dr. J. M. Lee of Rochester, N. Y.
Never having before seen or performed the operation, I followed as nearly as possible
the description given by Schroeder. After using an antiseptic vaginal injection, and
after anesthesia had been induced by the use of whiskey,* the patient was placed in
the lithotomy posture before a good light. An effort was first made to drag the
uterus down sufficiently with a strong pair of volsella forceps, but the tissues of the
cervix were so friable that the instrument would tear its way out.
The cervix was,
therefore, pierced with a needle properly threaded, which was carried as closely as
possible to the utero-vaginal junction. The long ends of the silk in the hands of one
assistant gave complete control of the organ, and made it possible to drag the cervix
down to the ostium vaginæ. Owing to the displacement of the anterior vaginal
wall, a large-sized male sound was introduced into the bladder. Guided by the
sound, an incision was made through the mucous membrane of the anterior lip, and
with one of Emmet's cervical knives the bladder was dissected from the cervix as far
as the peritoneum in front. Next the cul-de-sac of Douglas was opened into with a
pair of scissors, and the incisions carried laterally far enough to free the cervix upon
the two sides.
The index and little fingers of the left hand were next passed over the broad liga-
ments from behind and into the utero-vesical pouch. Cutting on these two fingers the
peritoneum was divided anteriorly. Seizing the uterus through the posterior opening
with a pair of forceps, the organ was retroverted and the fundus dragged into the
vagina. The left broad ligament was next transfixed with a quarter-curved Peaslee
* I have entirely discarded whiskey as an anesthetic.
660
A TEXT-BOOK OF GYNECOLOGY.
perineal needle, which carried with it a heavy piece of braided silk. After withdraw.
ing the needle the ligature was cut in the center, and each half of the ligament tied
separately. By the aid of a Wilson perineal needle another silk ligature was thrown
around the entire ligament and firmly tied. For fear these ligatures might slip, the
unnecessary precaution of including the entire mass in the jaws of a strong pair of
Spencer Wells ovariotomy forceps was taken. The forceps cut the ligatures and
necessitated the application of second ones. With a pair of scissors this ligament was
now severed about an inch from the uterus, when its fellow on the opposite side was
treated in the same way-an easy task compared with the difficulties in managing the
first. The tubes and ligaments showed no evidences of sarcomatous infiltration; the
left ovary, however, presented evidences of cystic degeneration, and was accordingly
removed. After thoroughly cleansing the pelvic cavity, a cruciform drainage tube
was inserted, the stump of each ligament being fixed in the corresponding angle of the
vaginal wound by a wire suture. The vagina was packed with antiseptic cotton, and
the free end of the drainage tube protected by plugging it with the same material.
Two knuckles of small intestine and a portion of the omentum descended after the
uterus was retroverted, but by carefully avoiding them they were not injured. The
patient was on the table just sixty-five minutes, and was placed in bed with her pulse
somewhat softened, but regular and full. It required about four hours for her to
regain consciousness.
During the first twenty-four hours following the operation the temperature did
not rise above 101°. It then fluctuated between this point and normal until the
evening of the 12th, when it reached 103°. This rise followed upon the removal of
the tube, and I decided to re-open the wound, and, in some way, permanently restore
drainage. Accordingly, the patient was anesthetized and I forced my finger through
the vault of the vagina into the pelvic cavity. In my effort to break up any existing
pus pockets that might have formed, I was not a little surprised to find my finger in
contact with a scybalous mass in the rectum, the accumulation of pus having des-
troyed the integrity of the intestine.
The idea of the opening into the rectum affording complete drainage did not at that
time occur to me. An effort was made to heal it over a rectal tube, which measure,
owing to the intolerance of the rectum, had to be discarded after twenty-four hours.
During the following eight or ten days water injected into the rectum would
pass out through the vagina, and a profuse flow of pus was discharged per rectum.
Fecal matter not infrequently made its appearance through the vaginal opening,
and as enemata were ineffectual in moving the bowels, a full dose of oil was
given on the sixteenth day after the operation. A large proportion of the liquid
feces following the administration of the oil passed into the vagina, and small
quantities of hardened feces continued to pass through the unnatural opening for
twelve days longer. With these exceptions the bowels moved regularly and normally
after the twenty-eighth day, and at the end of six weeks the fistula was entirely closed.
The patient has remained well up to the present date, July, 1893.
I believe that this is the first vaginal hysterectomy made
by a member of the homeopathic school, as it is also the first
recorded case in Michigan, and I report it somewhat at length
at this time that the reader may profit by the mistakes made.

TREATMENT OF MALIGNANT DISEASES OF THE UTERUS. 661
CASE LXXIII.-Carcinoma of the Body of the Uterus. Operation. Recovery.-
Mrs. M., æt. 31, referred to me by Dr. E. F. Chase of Dexter, Michigan; was married
at nineteen. She is the mother of three children, the youngest being six years old.
For three years preceding the operation she was kept almost exsanguinated by exces.
sive uterine hemorrhages and an offensive leucorrhea. Occasionally growths resembling
"bloody polypi" would come away. The uterus had been thoroughly curetted five
times without benefit. Before coming to the clinic I resorted to the curette under
anesthesia for diagnostic purposes. The curettings were submitted to Professor H.
Gibbes, Professor of Pathology in the University of Michigan, who found "unmis-
takable evidences of malignancy." On November 4, 1890, I performed vaginal
hysterectomy, securing the broad ligaments with forceps. Both ovaries and tubes
were removed, the right ovary being as large as an orange and cystically degenerated
(Fig. 148). The operation lasted but twenty minutes, and at least five minutes of
this time were consumed in securing a portion of the left broad ligament, which had
slipped from the grasp of a newly fashioned forceps, which, to my regret, I experi-
mented with. There was quite a good deal of capillary oozing, and I very foolishly,
FIG. 148.
CANCER OF THE UTERINE BODY, WITH CYSTIC DEGENERATION OF RIGHT
OVARY. (Wood.)
as subsequent events proved, crowded iodoform gauze into the vaginal wound for the
purpose of controlling it without stitching the surfaces of mucous membrane together.
Shock was intense, owing to the prostrated condition of the patient before the opera-
tion. After rallying from this she got on splendidly for the first ten days, having
scarcely any temperature and but little pain. The forceps and gauze were removed
at the end of thirty-six hours. With the removal of the gauze the omentum was
drawn into the vagina. This was carefully washed with a 1 : 10,000 bichlorid solution
and returned to the abdominal cavity, after which the vagina was again packed with
iodoform gauze. No bad results followed this accident, but on the tenth day urine
began to escape through the vagina and, three days later, none passed through the
urethra. A vaginal exploration revealed a piece of the gauze protruding through the
vaginal wound. After this was removed the fistula quickly healed under frequent
vaginal injections, and the patient is now (December, 1893) perfectly well. She left
the hospital December 2d, just one month from the day of her operation.
The iodoform gauze in this case was entirely unnecessary, as the oozing was not
alarming. I no longer use it without first partially closing the vaginal wound. The
fistula was undoubtedly due to sloughing, caused by the small portion left behind.
662
A TEXT-BOOK OF GYNECOLOGY.
CASE LXXIV.—Epithelioma of the Cervix. Operation. Death.—Mrs. W., aet. 32,
Kalamazoo, Michigan. Married for some years, but had never had children. History
of criminal abortion some years ago. Family history negative. One year ago her physi-
cian removed from the cervix two polypi, which were by him supposed to be non-malig-
nant in character. No subsequent examination was made until April 6, 1891, at
which time there was found springing from the cervix a fungoid mass which pro-
jected into the vagina; this was very vascular. She was referred to me, and presented
herself at my office for examination on the following day.
I found on physical exploration that the fundus could be moved by manipulating
the cervix. The vagina was exceedingly small and the perineum rigid. I could not
discover that the surrounding structures were implicated. The general health was
not yet involved. The case seemed a desperate one, but the patient was anxious to
take the chances attending vaginal hysterectomy.
After the usual preparation I operated five days following my first and only exami-
nation, in Borgess Hospital, Kalamazoo, being assisted by Drs. Denison, Cornell,
Ayers, and O'Brien. I anticipated much trouble, but my anticipations were more
than realized. It was necessary to carry the incision of the mucous membrane close
to the utero-vaginal junction in order to get above the diseased surface. The mucous
membrane was separated from the underlying cellular tissue with much difficulty, but
finally, with the finger and the handle of the scalpel, a dissection on either side was
made as far as the peritoneum. The peritoneum was exceedingly tense and was only
perforated by utilizing a sharp pair of dressing forceps. After its introduction it
was expanded and withdrawn in order to tear the peritoneum down to the broad
ligaments. The most difficult part of the operation was yet to come, viz., securing
the broad ligaments. An effort was made to drag the fundus of the uterus into the
vagina through either the anterior or the posterior opening, but without avail. The
base of the left broad ligament was first seized with a pair of strong forceps and
severed. Owing to the size of the vagina it was almost impossible to pass the forceps
high enough to seize more than a small portion of tissue at a time, and many instru-
ments were, therefore, required. After securing and cutting the lower half of the left
broad ligament, the right was dealt with in the same way, when the vagina was so full
of forceps as to make further manipulation within it impossible. I therefore incised the
perineal body through its raphé down to the sphincter muscle. This enabled me
to secure the upper half of the broad ligaments in the same way, after which the
uterus was freed and removed, with twelve pair of forceps left within the vagina.
The operation lasted two hours and was beset with difficulties that can only be appreci-
ated by those who witnessed it, or those who have undertaken a like one under similar
circumstances.
The patient rallied nicely from the operation and did well up to the end of the third
day. Evidences of intestinal obstruction then presented, and she died 24 hours later.
The large number of forceps required in this case had, I be-
lieve, something to do with the obstruction, although a post-
mortem was not permitted. At the time of operating I had
never experimented with Leopold's method of ligating the broad
ligaments. Its application, I am sure, would have been infinitely
less difficult than was forci-pressure.
CHAPTER XLIII.
CYSTIC AND ALLIED DISEASES OF THE
UTERINE APPENDAGES.
The cystic and allied diseases of the uterine appendages may
be classified as follows:-
I. Adenoid ovarian tumors :-
2. Cysts of the broad ligaments and
Fallopian tubes :-
3. Solid ovarian tumors :—
a) Simple cysts;
(b) Multiple cysts;
(c) Proliferous cysts;
(d) Dermoid cysts;
(e) Papillomatous cysts.
((a) Papillomatous cysts;
(b) Parovarian cysts;
(c) Enlargement of the hydatid of
Morgagni ;
(d) Hydrops folliculorum;
(e) Cysts of the Fallopian tubes, and
tubo-ovarian cysts.
(a) Fibroma (solid and cystic);
(b) Carcinoma (solid and cystic);
(c) Sarcoma (solid and cystic);
The diagram shown in Fig. 149, copied from Doran, clearly in-
dicates the supposed seat of origin of each variety of tumor given
in the foregoing classification. The student is advised to study
this diagram carefully. He must, however, bear in mind that
many points concerning the origin of these benign and malignant
growths are as yet unsettled.
ADENOID OVARIAN TUMORS.
Simple Cysts.-The coats of these cysts during their early
formation are membranous, translucent, and, histologically, do
not differ in any way from the natural structure of the Graafian
follicles. They are supposed to have their origin in a Graafian
follicle, either before or after its rupture. The walls are of
variable thickness and simply possess a surplus of material, its
elements being identical with those of ordinary fibrous tissue.
The epithelium lining their inner coat corresponds to that of the
663

12
13
FIG. 149.
11
ya
DIAGRAM OF THE STRUCTURES IN AND ADJACENT TO THE BROAD LIGAMENT.
(Doran.)
1a. Multilocular cystic tumor developed in parenchyma of ovary. 3. Papillomatous
cystic tumor of ovary in (2) tissue of hilum of ovary. 4. Simple broad liga-
ment cyst, independent of parovarium (10) and Fallopian tube. 5. A similar
cyst in broad ligament above tube, but not connected with it. 6. A similar cyst
close to (7) ovarian fimbria of tube. 8. Hydatid of Morgagni-this never ap-
pears to form a large cyst. 9. Cyst developed from horizontal tube of parova-
rium. 11. Cyst developed from a vertical tube-cysts of this kind form the
papillomatous tumors of the broad ligament. 12, 13. Track of obliterated duct
of Gärtner; papillomatous cysts are said to be developed along this track.
FIG. 150.
MULTILOCULAR OVARIAN CYST. (Doran.)
664
OVARIAN TUMORS.
665
tunica propria of the follicle. They are limited in size only by
the containing power of the abdomen.
There is a hypersecretion of the follicle which gives rise to, or
is associated with, hypertrophy of its walls. The walls vary in
thickness from an inch or more to the extreme point of tenuity.
Just why the Graafian follicles should undergo these remark-
able changes we do not know. It is probable that some irrita-
tion-chronic congestion or inflammation—is the starting-point of
the difficulty; or it may be that the follicles are so deeply seated
in the stroma of the ovary that, although the contained ovum is
ready for extrusion, it cannot find its way to the surface, the
succeeding changes giving rise to hypersecretion of fluid and
hypergenesis of the follicle walls. This is simply a theory; yet it
is in harmony with the clinical fact that very frequently ovarian
tumors are preceded or attended by dysmenorrhea, chlorosis,
anemia, etc.-conditions which would tend to interfere with the
function of ovulation.
Multiple Cysts.-These are formed exactly as are simple
cysts, except that two or more Graafian follicles in apposition
grow simultaneously (Fig. 149, 1a), one cavity generally predomi-
nating. As time goes on the septa separating the several cysts
are absorbed or broken down, so that the tumor, while it does not
always become converted into a unilocular cyst, is transformed
into a cyst containing from two to four or five loculi only. It
will thus be seen that a multiple cyst is simply an aggregation
of single cysts.
Ovarian cysts may occasionally have their origin in the deep
areolar tissue of the ovary or among the vessels of the gland,
having no connection whatever with the Graafian follicles. The
exact modus operandi by which these cysts are produced is not
certain. It is probable that there is first a small deposit of fluid
in one of the areolar spaces, which is followed by the produc-
tion of a limiting capsular membrane. Possibly, as suggested
by Edis, "it is allowable to retreat a step further for explanation
and fall back upon the easily aroused innate power of evolution
of the plastic nuclei as well as of the tissue."
Proliferous Cysts.-These are also known as compound, com-
·posite and complex cysts. They have the same origin as those
666
A TEXT-BOOK OF GYNECOLOGY.
already given, although they may be located in any part of the
body where epithelial structures are found. They are charac-
terized by endogenous and exogenous growths-the former
springing from the inner surface of the parent cyst, the latter
from its outer surface.
These cysts vary greatly in fertility. There may be but a
single cluster of secondary cells hanging within the cavity of the
parent cyst or upon its outer surface; or cysts may grow from
all sides of the parent cyst, compressing each other to suicidal
repletion. Smaller cysts frequently grow from the outside of
the secondary cysts, from which another group may spring.
Contents of Simple and Multiple Cysts.—In simple cysts
the fluid may be perfectly colorless, hyaline, or of a pale yellow
or straw color. It is usually thin and limpid. Its specific grav-
ity varies from 1007 to 1018, and the quantity from an ounce to
one hundred and fifty pounds.
In multilocular cysts all kinds of fluid may be found in the
different loculi. In the chief loculus it may be thin, not differ-
ing from that found in simple cysts; other loculi may contain a
firm, jelly-like, or colloid material; or pus, blood, etc. The con-
tents of proliferous, like those of multiple cysts, are variable.
Chemically, Eichwald divides the contents into two classes: (1)
The mucous series, which consists of mucin, mucus, peptones,
colloid material, and the material of colloid globules; (2) the
albumin series, which consists of albumin, albumin peptones
(fibrin peptone), metalbumin, and paralbumin.
Microscopically, the following substances are found: crystals
of cholesterin, blood corpuscles, pus cells, compound granular
cells, inflammatory globules of Gluge, epithelial cells, globules
of fat, and disintegrated blood. The granular cell is the micro-
scopical product most unifor.nly present; the others enumerated
are not of so constant occurrence.
Dermoid, or Cutaneous Piliferous Cysts.-These cysts
frequently develop before puberty, and, while occasionally found
in combination with other cysts, they are always congenital in
origin.
Causation.—The generally accepted view of the origin of
these growths is that they are due to the displacement of the

OVARIAN TUMORS.
667
external blastodermic layer during the formation of the fetus.
The epidermis and other structures found in the contents of
dermoid cysts are developed from this layer, and if it is included
in that portion of the middle layer from which the
ovary
is
FIG. 151.
A DERMOID CYST, WHICH CONTAINED HAIR, TEETH, AND FATTY MATTER.
Its exterior is covered with long, shaggy adhesions, through which it was supplied
with sufficient blood to maintain its nutrition, the pedicle having atrophied. A
thick mass of hair will be seen on its inner wall. (Museum R. C. S. Photographed
by the Author.)
formed, the rudiments of a dermoid cyst are left in the ovary.
(Williams.)
Formerly it was thought that they were due to the early in-
clusion of an imperfectly developed ovum within one perfectly
668
A TEXT-BOOK OF GYNECOLOGY.
developed. Still another hypothesis is that they result from the
imperfect development of an impregnated ovule. The first theory
is hardly tenable; as for the second, it is only necessary to say
that dermoid cysts are found in young children, and cannot,
therefore, possibly depend upon conception.
Pathology. The cyst wall is composed of two distinct layers,
an inner and an outer. The former is not unlike the skin in
structure, its lining membrane being composed of pavement epi-
thelium. Underneath the epithelium is a layer corresponding
to the cutis, though the papillæ are irregularly rounded without
any regard to parallel rows. The tegumentary appendages-
sebaceous and sweat glands, hair follicles, etc.—are contained in
a mass of loose areolar and adipose tissue which underlies that
corresponding to the cutis. In this layer there is also frequently
found laminæ or spiculæ of bone, frequently of an irregular shape,
though having the true structure of bone. Rudimentary or per-
fectly formed teeth are also found in this layer; or they may
project from the stroma of the cyst wall. (Edis.)
The fluid is gen-
The contents of dermoid cysts are variable.
erally of a pultaceous, greasy nature, and is made up of free fat,
cholesterin crystals, and cast-off epithelial cells. The solid sub-
stances are tufts of hair* (Fig. 151), balls of fat, and teeth,
varying from one to one hundred in number. Other sub-
stances—bone, brain substance, muscular fibers, and nerves—are
occasionally found.
These cysts usually contain but one loculus, though they are
sometimes compound.
Papillomatous Cysts.-When these cysts have their origin
in the ovary they start in the tissue of the hilum (Fig. 149, 2).
They contain variable quantities of papillomatous or cauliflower
growths.
Papillomatous growths are occasionally found in common.
multilocular ovarian tumors commingled with adenomatous
masses. Papillomatous ovarian cysts usually have a short
pedicle, or the tumor not infrequently is intraligamentary.
* Mundé found in one case a switch of hair which, after being immersed in ether,
measured five and a half feet in length and was as thick as the wrist in its entire
length.

CYSTS OF THE BROAD LIGAMENTS.
669
CYSTS OF THE BROAD LIGAMENTS.
Papillomatous Cysts.-These may be either uni- or multi-
locular. Their cavities contain the same papillomatous growths
as are found within papillomatous cystic tumors of the ovary.
Masses of the tissue may invest the uterine appendages (Fig. 152),
completely covering the ovarian surface. There is a great ten-
dency for these growths to infect the peritoneum. Doran believes
that papillomatous growths of the ovary and the broad ligament
FIG. 152.
PAPILLOMATOUS DISEASE OF THE BROAD LIGAMENTS, COMPLETELY HIDING THE
APPENDAGES.
These growths may have been enclosed at an early stage in a cyst-wall. (Museum
R. C. S. Photographed by the Author.)
have their origin from the tubes of the Wolffian body in the hilum
and parovarium.
Papillomata, wherever found, may be either benign or malig-
nant. They consist of hypertrophy of the papillæ either from
the interior or exterior of the glandular cyst. During their
early formation they are nothing more than warty growths such
as may occur from any surface or any part of the body. They
are, however, liable at any time to undergo malignant degenera-

FIG. 153.
AN OVARY WITH THE BROAD LIGAMENT AND FALLOPIAN TUBE.
There is a thin-walled parovarian cyst, two inches in diameter, between the layers
of the broad ligament. The terminal part of the Fallopian tube is attached over
its surface. The anterior layer of the broad ligament is partly dissected off from
the cyst. (Museum R. C. S. Photographed by the Author.)
FIG. 154.
PAROVARIAN CYST.
The Fallopian tube, which is much elongated, is seen above. The posterior layer of the
broad ligament has been horizontally divided, so as to expose the cyst which appears
to be unilocular, and very thin-walled, without any intra cystic growths. The ovary,
laid open, lies to the left. (Museum R. C. S. Photographed by the Author.)
670
SOLID TUMORS OF THE OVARY.
671
tion; hence the necessity of early operative interference before
the surrounding structures are implicated.
Parovarian Cysts.—(Figs. 153 and 154). These cysts are
found between the layers of the broad ligament. They are thin-
walled and almost invariably unilocular. Their contents consist
of a clear watery fluid of low specific gravity which is non-album-
inous. They are generally pedunculated, not extending as far
as the uterus between the folds of the broad ligament.*
Enlargement of the Hydatid of Morgagni.-This small body,
shown in Fig. 149, rarely develops into a cyst large enough to
call for operative interference. It is here mentioned simply to
make the classification of cysts of the ovary and its appendages
complete. (Doran.)
The other varieties of cyst included in the classification
require no extended description at this time. The cysto-fibroma
and myxo-adenoma are simply forms of degeneration of solid
tumors. Hydrops folliculorum, cysts of the Fallopian tubes, and
tubo-ovarian cysts, are dealt with in the chapter devoted to chronic
diseases of the appendages.
SOLID TUMORS.
Fibroid Tumors of the Ovary.-These growths consist
chiefly of fibroid tissue resulting from hypertrophy of the stroma
of the ovary. They are of exceedingly rare occurrence, and it is
probable that fibroid tumors of the uterus involving the ovary
have been more than once mistaken for true ovarian fibroma.
Occasionally muscular fiber-cells are found here and there
throughout the mass. Ovarian fibroid tumors vary in density,
and not infrequently contain loculi or cysts, constituting the so-
called fibro-cystic ovarian tumors. Sometimes they possess a
loose vascular texture and resemble in their appearance malig-
nant growths. (Williams.)
So long as the tumor does not undergo cystic degeneration it
never attains a large size—usually not larger than a fetal head.
Fibro-cystic tumors, on the other hand, not infrequently attain
a large size, often growing very rapidly.
In the event of cystic degeneration, the partition dividing the
* "The true parovarian origin of this kind of cyst is questionable.”—Doran.
672
A TEXT-BOOK OF GYNECOLOGY.
cysts often consists of a very vascular fibrous mass from which
hemorrhages may proceed, filling the cyst cavity with blood.
Occasionally they undergo certain degenerative changes, becom-
ing calcified, gangrenous, or they may suppurate. The last two
changes are usually due either to twisting of the pedicle or to
traumatism.
Carcinoma.-Carcinoma of the ovary is more frequently met
with than is fibroma. It may be either primary or secondary.
Any of the forms of cancer attacking other parts of the body
may implicate the ovary. The peculiar character of the ovarian
tissue, composed as it is of a fibrous stroma with a dense investing
membrane, of Graafian follicles, and of intra-follicular epithelium,
which is ever growing, especially favors the development of the
various forms of cancer.
Malignant cystic tumors of the ovary may occur in one of two
ways: First, the walls of a benign cystic tumor may undergo
cancerous degeneration; second, infiltration and disintegration
may take place in the structure of scirrhous and medullary can-
cers, as in fibroma, thus forming a cyst.
Sarcoma. Sarcomas frequently undergo cystic degeneration,
so that they are met with both as solid and cystic tumors. In
many instances they grow rapidly and reach a very large size.
Histologically, they present the characteristics of sarcoma found
in other parts of the body.
Formerly the excessive amount of solid material in polycystic
tumors was supposed to indicate sarcoma, and undoubtedly cases
of benign tumors were many times incorrectly classified as
sarcoma.
The Pedicle of Ovarian Tumors. The pedicle varies in
length and thickness as well as in consistence. It may be long
and slender—not larger than the little finger; or it may be broad
and thick. It is composed of the Fallopian tube, broad liga-
ment, and ovarian ligament and vessels. It is, of course, covered
by peritoneum. The blood, the nerve, and the lymphatic supply
of the tumor pass through the pedicle.
A considerable space may intervene between the broad liga-
ment and Fallopian tube and the utero-ovarian ligament, so that
the tumor may seem to have two pedicles. Not infrequently the
Fallopian tube is much elongated and usually it is thickened.
!
CHAPTER XLIV.
CYSTIC AND ALLied diseASES OF THE
UTERINE APPENDAGES-(Continued.)
SYMPTOMS.
Ovarian Cysts.-The symptoms of an ovarian cyst will de-
pend upon its size and location. When small it may exist for
an indefinite length of time without giving rise to trouble. If,
however, it remains within the pelvic cavity, the neighboring
organs are liable to be impinged upon in such a way as to cause
inconvenience. Dysuria is often excited by the tumor pressing
upon the bladder. If it falls into the posterior cul-de-sac, there
will be more or less irritation of the rectum; and, should it
become incarcerated, complete obstruction of the bowel may
result. The uterus is pushed forward or backward according to
the location of the tumor.
The menstrual symptoms also vary greatly. I have already
noted the fact that ovarian tumors are frequently preceded or ac-
companied by dysmenorrhea. If but one ovary is involved, the
menstrual function is not necessarily affected in any way; or,
indeed, if but a portion of one ovary is left intact, ovulation may
occur as usual, and menstruation is not necessarily painful.
Amenorrhea is probably a more frequent symptom than is
menorrhagia, though excessive menstruation is sometimes the
result of ovarian tumors. The reflex symptoms are often suffi-
ciently marked, even with small tumors, to cause suspicions of
pregnancy. The stomach may be more or less disturbed, so that
there is a tendency to flatulency, which increases the size of the
abdomen. The breasts may also undergo reflex changes which
adds to the uncertainty of diagnosis.
When the cyst increases in size and becomes large it passes
into the general abdominal cavity, unless it is held in the pelvis
by adhesions. The pressure upon the pelvic organs is now re-
43
673
674
A TEXT-BOOK OF GYNECOLOGY.
lieved, and until the tumor becomes sufficiently large to interfere
with the abdominal viscera the patient suffers less than when it
was confined to the pelvis. As it becomes larger there will be
a sensation of fulness because of the pressure upon the stomach
and bowels. Respiration is interfered with, giving rise to dysp-
nea; the digestion is disordered, and the pressure upon the
kidneys, liver, and other organs adds greatly to the patient's
discomfort. As time goes on emaciation becomes marked and
there appears a peculiar expression to the face which is known
as the facies ovariana.
Edema of the lower extremities, from pressure, occurs as a late
symptom. Gastritis not infrequently supervenes as the case pro-
gresses from bad to worse. The patient can no longer digest or
assimilate food; nutrition reaches its lowest ebb; and, worn out
by the dyspnea and other symptoms resulting from pressure,
death ensues.
Dermoid Cysts.-These cysts frequently make their presence
known at or about the period of puberty when the changes
incident to that period cause them to take on active growth.
They grow slowly, and usually do not attain a size larger than
that of an adult head.* Owing to the thickness of the walls and
the nature of the contained fluid, fluctuation is generally very
indistinct, and it may be impossible to detect it at all. The osseous
contents may be felt projecting through the cyst wall. Dermoid
cysts frequently undergo suppuration, especially during preg-
nancy and parturition. As a result, adhesions occur oftener than
in simple or multiple cysts, and their contents may escape through
the bladder, bowel, or abdominal wall. Unfortunately, sponta-
neous cures rarely result in this way, and without operative
interference suppuration will continue indefinitely. Rupture
rarely if ever takes place into the abdominal cavity.
Cysts of the Broad Ligament.-Those cysts of the broad
ligament which arise from dilatation of the remains of the
Wolffian body or vesicles of the tube are always of small size
and rarely become larger than an egg. They hang from the sur-
* I removed during the spring of 1893 a dermoid cyst which, together with its con-
tents, weighed thirty-four pounds.
SYMPTOMS OF OVARIAN TUMORS.
675
face of the ligament by a long, slender pedicle, have very thin
walls, and are covered by peritoneum. Their contents are of
a perfectly innocent character, and they seldom give rise to any
trouble. They are rarely detected except upon post-mortem
examination, or upon abdominal section for other causes.
The so-called parovarian cysts, on the other hand, because of
their size, are of greater importance. The parovarium, or organ
of Rosenmüller, analogous to the epididymis in the male, is a
small body situated between the folds of the broad ligament and
between the outer extremity of the ovary and the Fallopian tube.
These cysts are formed by a distention of one of the tubes of
the parovarium, and, in exceptional instances, may become large
enough to fill the abdomen. They occur oftener in young
women, grow slowly, and ordinarily do not attain any consider-
able size. They are usually single, and the constitutional symp-
toms attending their growth are not marked.
While in most instances they are pedunculated, yet there is a
greater tendency for them to burrow between the folds of the
broad ligament than is the case with ovarian cysts. They are
distended with a watery, limpid fluid of low specific gravity,
seldom exceeding 1005, the fluid containing a trace of albumen,
which usually requires both heat and nitric acid to precipitate it.
Owing to the thinness of the cyst walls, fluctuation is more dis-
tinct than in ovarian cysts.
Fibroid Tumors of the Ovary. The symptoms of fibroid
tumors of the ovary do not differ essentially from pedunculated
subserous fibroid tumors of the uterus. Indeed, in many in-
stances it is utterly impossible to differentiate the two conditions.
It will not do to rely upon the mobility or fixity of the tumor
in differentiating the two, because a subserous uterine fibroid
possessing a long pedicle is often quite as mobile as is a fibroid
tumor of the ovary. These growths are differentiated from
cystic tumors of the ovary by the fact that they are hard and
give no evidences of fluctuation. They grow much less slowly
than does cancer, and the constitutional symptoms are not usually
so profound. However, any of the solid tumors, either benign
or malignant, when undergoing cystic degeneration, may
increase in size with great rapidity.
676
A TEXT-BOOK OF GYNECOLOGY.
Cancer of the Ovary.-Thomas formulates the following
symptoms as suggesting malignant involvement of the ovary:-
1. Rapid development of a solid tumor in the ovary;
2. Marked depression of the vital forces and general condition
of the patient;
3. The occurrence of edema pedum and spanemia with a
small tumor, which are, consequently, dependent upon
the general blood state, and not the result of pressure by
the tumor;
4. Lancinating and burning pains through the tumor;
5. Cachectic appearance;
6. The occurrence of ascites without evidences of cirrhosis
or other hepatic diseases, organic diseases of the kidneys,
or of the heart, or chronic peritonitis.
Let the reader bear in mind that while the foregoing symptoms
suggest malignancy, too much reliance cannot be placed upon
them. Indeed, let him ever bear in mind, when dealing with
abdominal tumors, that there is nothing so utterly unreliable as
subjective phenomena. During the college session of 1890-91
I had this fact most emphatically impressed upon me by the
following case :*—
CASE LXXV.—The patient, an American, aet. sixty-three, was referred to me by
Dr. Mills of Howell, Michigan. The abdomen was large and evidently contained a
tumor of some kind. It apparently was cystic, but not monocystic. Until coming to
the hospital she worked daily with but little inconvenience. There was no pain, no dis-
turbance of digestion, and the appetite was good. On making the first examination,
however, two; symptoms-early emaciation, and the quantity of ascitic fluid which
seemed to be present-aroused my suspicions of malignancy, and I so announced
to the class and to her medical attendant, who was present. Other than these symp-
toms, there were absolutely no evidences of malignancy.
On April 24th I made an exploratory incision and found the pelvis absolutely filled
with the products of malignancy. I carefully closed the wound after removing the
ascitic fluid. The patient came very near dying from immediate shock, and was only
saved by the most energetic measures. She finally rallied, passed through the night
splendidly, and the next morning was feeling unusually well, with bowels and tem-
perature normal. At 10 A. M. she began to vomit "typical coffee-grounds matter,"
and rapidly passed into collapse, dying two hours later.
A post-mortem was made four hours after death by Dr. Rogers, assistant patholo-
gist of the University. The peritoneum was studded with cancerous nodules, as was
also the omentum. The omentum was closely adherent to the tumor. The tumor
* North American Journal of Homeopathy, July, 1891.

SYMPTOMS OF OVARIAN TUMORS.
677
sprang from the right side, and the pelvis and abdomen were literally packed with
tumor, uterus and broad ligament, all of which were implicated in the cancerous
process, and from the entire surfaces of which projected malignant nodules (Fig. 155).
The intestines were dark, nodular, and matted together. The liver was indurated,
and contained one nodule which was undoubtedly cancerous. The gall-bladder was
enormously distended and contained nearly a pint of fluid. The stomach was so soft
FIG. 155.
CANCER OF UTERUS AND ANNEXA. (Wood.)
that it could be readily torn with the finger, and was filled with the peculiar dark gru-
mous matter similar to that vomited just before death.
Notwithstanding the fearful inroads of malignancy, there were no subjective symp-
toms, other than those mentioned, suggesting the condition present. It is true that
the patient had been under the care of her physician at various intervals for years, but
until the tumor made its appearance her symptoms yielded kindly to treatment, and
she had never been seriously ill.
678
A TEXT-BOOK OF GYNECOLOGY.
COURSE AND TERMINATION.
The course and termination of ovarian tumors will depend
upon the age of the patient and the nature of the tumor, as well
as upon the many contingencies liable to arise. Monocystic
tumors of the ovary grow, as has been shown, more slowly than
do multiple cysts. Solid fibroid tumors often continue for an
indefinite length of time without giving rise to any trouble,
and are not necessarily fatal unless they undergo some of the
forms of degeneration which have been referred to. On the
other hand, malignant tumors grow with great rapidity and
speedily terminate life by undermining the patient's health, or
by giving rise to serious complications, unless their progress is
· interrupted by operative procedures. Proliferous cysts likewise
grow with great rapidity, while a dermoid cyst may be carried
through life without the patient being aware of its existence;
however, suppuration is liable to arise at any time. The slow
growth of parovarian tumors has already been noted. These
growths do not usually return after tapping; but, owing to the un-
certainty of diagnosis, we are not justified in resorting to tapping
as a curative procedure. This point will be referred to later on.
The contingencies requiring consideration are:-
Spontaneous cures, and cures by internal medication;
Twisting of the pedicle;
Rupture of the cyst;
Inflammation of the interior of the cyst;
Hemorrhage from the interior or exterior walls of the cyst;
Adhesions;
Obstruction of the bowel.
The spontaneous disappearance of ovarian cysts by absorption
alone is extremely doubtful, notwithstanding the fact that
instances of the kind have been recorded. Nearly all specialists
are agreed that so long as the fluid remains within the cyst
absorption is impossible. Should rupture occur, and the con-
tained fluid escape into the peritoneal cavity, it is entirely
possible for the fluid to be absorbed; or should rupture fortu-
nately take place into the bladder, bowel, or Fallopian tube, the
contents may escape through one of these channels. Post-
OVARIAN TUMORS-CONTINGENCIES.
679
mortem evidence is not wanting to show that a tumor may
gradually atrophy from insufficient nourishment by twisting of
the pedicle. I am aware of the fact that, especially in homeo-
pathic literature, many cases of alleged cures following the
administration of the indicated remedy are reported. Some of
them are reported by men whose authority as gynecological
specialists is fully established. Nevertheless, the possibilities of
curing these cases by internal medication are so remote, that the
cysts should not be permitted to continue without operative inter-
ference until life is jeopardized by their excessive growth. I have
so often had come to me, patients, on whom internal medication
had been unsuccessfully tried, and who should have been operated
upon months before, that it almost leads me to regret that such
cures were ever reported. In alleged cures, the uncertainties of
diagnosis should always be borne in mind.
Twisting of the Pedicle.-This is not an infrequent accident,
the axillary rotation of a tumor free from adhesions twisting the
pedicle so as to obstruct its circulation. In the New York Medical
Journal for May, 1891, Robertson reports five cases of twisting
of the pedicle of tumors occurring in the practice of Lawson
Tait. Tuholske * also reports two cases of the accident, in
one of which the pedicle was twisted one and a half times
and in the other two and a half times. In one of Lawson Tait's
cases the tumor doubled in size in three days. This, as suggested
by Robertson, is due to the fact that the twisted pedicle allows
the arterial blood to pass into the tumor long after the venous
blood is cut off. Rapid increase in the size of a tumor should
cause one to be on the alert for twisted pedicle. In one of Tait's
cases the patient was seventy-eight years old. The twist occurred
while she was getting into bed, and the tumor rotated on its
axis between three and four times. After operating the patient
made a good recovery. In another case gangrene set in as the
result of strangulation; and in still another the tumor was
filled with pus, the twist probably occurring more gradually.
In all of the five cases reported, adhesions had formed to the
surrounding structures through which the nutrition was almost
entirely derived, the circulation of the pedicle being cut off.
* St. Louis Courier of Medicine, December, 1890.
680
A TEXT-BOOK OF GYNECOLOGY.
The twist may be only partial, so that the circulation is not
entirely cut off, and gradual atrophy of the tumor, as observed
under the head of spontaneous cures, may come about. Un-
fortunately, this termination is of exceedingly rare occurrence.
The pedicle, as a result of the twisting, may become entirely
separated from its attachment, when the tumor will be found
either loose within the abdominal cavity or attached to some of
the surrounding viscera by adhesions.
Rupture of the Cyst.-Every operator of experience has met
with instances where cysts have ruptured and discharged their
contents into the peritoneal cavity. The accident is especially
liable to occur when the cyst walls are thin and tense, and when
the case is complicated by pregnancy. Other causes are: direct
violence, concussion, a fall or sudden blow.
The symptoms of rupture are those of shock with subsequent
peritonitis. The shock is sometimes very great, and, if asso-
ciated with hemorrhage, death may ensue at once. The extent
of peritonitis excited will depend upon the nature of the fluid,
being much more marked when the latter is gelatinous or puri-
form.
As has already been shown, spontaneous cure may follow the
rupture. Oftener, however, if the patient recovers from the
shock and peritonitis, the tumor will refill.
Inflammation of the Interior of the Cyst.-The same causes
which give rise to rupture may give rise to inflammation. When
tapping was a more common practice the accident was met with
much oftener than it is at the present time. In multilocular
cysts the inflammation may be limited to one loculus. When the
inflammation is succeeded by suppuration, as frequently occurs,
all of the symptoms of septicemia and pyemia may ensue; or
the decomposed fluid may find its way through adhesions either
into one of the cavities of the body; or externally through the
abdominal walls. Dermoid cysts are particularly liable to
undergo inflammation and suppuration.
Hemorrhage from the Interior or Exterior Walls of the
Cyst.-This may result from injury which does not give rise
to rupture. It is often associated with papillomatous degenera-
tion. The symptoms will depend upon the quantity of hemor-
OVARIAN TUMORS TERMINATIONS.
681
rhage and upon the seat of the effusion. If very great all the
symptoms of shock will present themselves. If it escapes into
the free peritoneal cavity the ordinary symptoms of hematocele
follow. Peritonitis is not infrequently excited by the accident.
When a large quantity of blood is poured into the cyst cavity,
the tumor is suddenly distended; this form of hemorrhage is
oftener the result of twisting of the pedicle.
Adhesions.-Adhesions are of frequent occurrence. The
tumor may attach itself to any of the pelvic or abdominal viscera,
or to the abdominal walls. The liver, the stomach, and the
diaphragm may thus become attached to the tumor. As a result,
the contents of a cyst undergoing degenerative changes may find
their way into any of the hollow viscera contained within the
pelvis and abdomen, or even through the diaphragm into the
lungs and pleural cavities.
When adhesions exist, a history of peritonitis can usually be
obtained.
Obstruction of the Bowel.-This may be due either to di-
rect pressure of the tumor, or to inflammatory adhesions follow-
ing inflammation and suppuration. Its presence is announced
by the usual symptoms attending obstruction.
Terminations.-Death may result from-
Exhaustion;
Asphyxia;
Suppuration and pyemia;
Peritonitis;
Collapse and shock from rupture of cyst;
Intestinal obstruction;
Uremia;
Hemorrhage either into the cyst or into the free peritoneal
cavity from the external surface of the cyst;
Twisting of the pedicle.
Death is usually caused by a combination of two or more of
the foregoing causes: The surgeon having in charge a patient
with an ovarian tumor should constantly bear in mind the com-
plications liable at any time to arise. He should, moreover, if
the patient declines to submit to immediate operative interference,
hold himself in readiness to open the abdomen, unless positive
682
A TEXT-BOOK OF GYNECOLOGY.
counter-indications exist, as soon as dangerous symptoms mani-
fest themselves. A high temperature, instead of being a counter-
indication, usually calls imperatively for surgical interference ;
it is due, in the vast majority of instances, to suppuration. I
have seen the temperature drop in a few hours from 105° to
normal after removing a suppurating multilocular cyst.
Prognosis. While the course of the several forms of ovarian
tumors which have been studied is most variable, the tendency
in all is toward a fatal termination unless interrupted by surgical
art; and while a tumor, in a given case, may exist for years
without giving rise to serious trouble, the instances where this
is so, are of such exceptional occurrence as to have little influ-
ence in determining the probable outcome of the disease. In
the vast majority of instances, the end is only a question of time,
if the tumor is unmolested. On the other hand, the average
mortality of the best ovariotomists is but six per cent.-so that
the whole outlook is at once changed by the intervention of art.
CHAPTER XLV.
CYSTIC AND ALLIED DISEASES OF THE
UTERINE APPENDAGES-(Continued).
DIAGNOSIS.
The existence of an ovarian cyst may be suspected if the
abdomen is enlarged by a tumor which has made its appear-
ance gradually, and which does not present the ordinary signs
of pregnancy; which has grown from below upwards; which
is mobile; which is not tender; and which does not affect the
general health until the tumor is large enough to interfere with
the functions of the abdominal viscera. Subjective symptoms
alone, as I have already emphasized, are entirely insufficient for
purposes of diagnosis. Nothing short of thorough physical ex-
ploration will suffice; and even then the physician will many
times be left in doubt until after the abdomen is opened. Ex-
tended experience in abdominal surgery begets modesty. In the
language of Tait: "Exact abdominal diagnosis is an impossi-
bility, and he who asserts to the contrary is either rash or inex-
perienced."
The uncertainties of diagnosis, instead of making the physician
less thorough in his methods of examination, should make him
more so. So much is at stake in dealing with abdominal
tumors that anything less than thoroughness is criminal. More
than once has the abdomen been opened for the purpose of
removing an ovarian tumor when no tumor was found; or
when, instead of an ovarian tumor, a pregnant uterus was dis-
covered. Besides these sources of error, the chastity of virgins
is frequently impugned when the cause of the enlargement of
the abdomen, instead of being a pregnant uterus, is an ovarian
For these reasons, as well as for many more which
suggest themselves, the examiner cannot proceed with too great
tumor.
683
684
A TEXT-BOOK OF GYNECOLOGY.
care when he suspects the existence of a tumor of any kind
within the abdomen or the pelvic cavity.
In the chapters devoted to physical diagnosis, I have dwelt at
length upon the manner of conducting physical examinations.
I shall, therefore, at this time touch only upon a few points espe-
cially important in examining for abdominal tumors.
The examiner should proceed at all times with extreme
gentleness. If pain is caused by palpation or by the bimanual,
contraction of the abdominal muscles will be excited. When-
ever there is any doubt as regards the contents of the abdomen
or pelvis an anesthetic should be administered.
This is es-
pecially true in dealing with nervous and hysterical patients, or
with young girls who have never before been subjected to a
physical examination.
Pain excited by the manipulations of the surgeon does not
necessarily indicate disease. Indeed, hard pressure upon any of
the structures within the pelvis or the abdomen will give rise to
more or less pain. Suffering may also be induced by the care-
lessness of the examiner who has not properly cared for his
nails, or who is unduly awkward. Again, the examiner should
constantly bear in mind the possibilities of pregnancy. Unless
he does there is danger, even in the examination of supposed
virgins, of unwittingly producing abortion. No matter what
the patient's station in life may be, or what her environ-
ment, the examiner's only safety will lie in looking upon the
girl or woman as a being capable of conception. Too often
errors have arisen from the physician's relying implicitly upon
the patient's statement regarding the persistence of the
catamenia.
Finally, the surgeon should not assert the results of his exam-
ination with too much positiveness. He may, it is true, be able
to make his diagnosis with almost absolute certainty. Unfor-
tunately, this is not always the case, and after exhausting every
known method and every precaution, he will every now and then
open the abdomen only to find himself mistaken. He should,
therefore, be careful to explain to the patient and her friends that
an element of uncertainty always prevails. This precaution may
save him much future embarrassment.
DIAGNOSIS OF OVARIAN TUMORS.
685
The chief causes of erroneous diagnosis after examination are
enumerated by Doran as follows:
I. Preconceived ideas;
*
2. Over-confidence in the patient's history;
3. Omission of precautions;
4. Faulty palpation and percussion ;
5. Real difficulties.
Preconceived Ideas.-Preconceived ideas are formed usually
because the surgeon has had presented to him, either by the
patient or by her medical attendant, a history which leads him
to suspect ovarian tumor. Upon examination he finds that the
abdomen is unquestionably enlarged, but does not take the pre-
caution to eliminate the misleading conditions presently to be dealt
with.
Over-confidence in the Patient's History.-The surgeon
must proceed in his physical examination entirely unbiased by
the patient's history. This is true in the case of respectable
married women as well as in young unmarried women. In the
first instance, the patient may consider herself pregnant because
she has experienced sensations similar to those experienced
during previous pregnancies; or she may not consider herself
pregnant because the usual symptoms attending previous preg-
nancies are absent. In the case of young single women, the
symptoms of pregnancy, if they exist, may be suppressed. The
surgeon must, too, bear in mind that pregnancy may occur after
amenorrhea has existed for a long time.
Omission of Precautions.-A distended bladder may give
rise to uncertainty of diagnosis before the catheter is intro-
duced; or a loaded rectum or sigmoid flexure may lead one to
suspect the existence of a tumor other than fecal, hence the
necessity of having both the bowels and the bladder thoroughly
emptied before the examination is begun. A still more im-
portant precaution is the use of an anesthetic when there is very
great tenderness or rigidity of the abdominal walls, or when there
is much flatulency.
*"Gynecological Operations," p. 172, 1887.
686
A TEXT-BOOK OF GYNECOLOGY.
Faulty Palpation and Percussion.—Palpation and percus-
sion should be conducted in such a way as to cause the least
possible amount of pain. The entire hand or the entire finger
should be used instead of the tips of the fingers, for the latter
will cause sufficient pain to incite contraction of the recti
muscles. The hands should also be warm and the patient
placed in a position favorable to the relaxation of the muscles.
Real Difficulties.-These comprise excessive thickness of
the abdominal walls, excessive tenderness, the simultaneous
existence of tumors and pregnancy, rupture of the cyst walls,
peritonitis, etc. It is when these various difficulties are met.
with that the skill of the examiner is taxed to the utmost.
DIFFERENTIATION.
I shall follow Doran's* classification in differentiating the
various conditions giving rise to abdominal distention. It is as
follows:-
CLASS I.-A Tumor or Tumors more or less Distinct.
1. A central tumor, distending lower part of abdomen.
A. Freely fluctuating.
Ovarian cyst, with one cavity greatly predominating
over the others;
Broad ligament cyst;
Encysted dropsy of peritoneum ;
Distended bladder;
Hydramnios.
B. Fluctuating in parts.
Ovarian cyst, multilocular;
Ovarian cyst with much solid matter;
Fibro-cystic uterine tumor;
Pregnancy (later stages).
C. Solid, no fluctuation.
Solid ovarian tumor;
Fibroid uterine tumor;
Pregnancy (earlier stages).
* Op. cit., p. 174.
DIAGNOSIS OF OVARIAN TUMORS.
687
2. A tumor distending lower part of abdomen, not central in
position.
A. Fluctuating.
Renal cyst or retro-peritoneal cyst in the neighbor-
hood of the kidney;
Cyst of omentum or mesentery;
Hydrosalpinx (extreme cases);
Ovarian cyst (rare);
Cyst in abdominal walls;
B. Solid.
Extra-uterine pregnancy (tumor may be central);
Scybala in cecum or sigmoid flexure;
Enlarged spleen (extreme cases);
3. Two or more tumors distending lower part of abdomen.
Bilateral ovarian tumors (especially small dermoid
cysts);
Multiple subperitoneal uterine fibroids.
Hydatid disease of peritoneum.
Class II.-Abdomen Distended; no Distinct Tumor.
I. Fluctuation distinct.
Ascites (all cases including those where an ovarian or
other tumor may exist).
2. No fluctuation.
Tympanites and phantom tumor;
Obesity;
Pendulous abdomen.
CLASS. I.-A TUMOR OR TUMORS MORE OR LESS DISTINCT.
1. A Central Tumor, Distending Lower Part of Abdomen.
A. Freely Fluctuating.
Ovarian Cyst, with one cavity greatly predominating over
the others. This will give rise to dulness on percussion in the
lower part of the abdomen. It occupies the middle line, or is
slightly to one side, and can be located by palpation. The area
of dulness does not change. It is movable en masse only or
not at all. There is resonance in the flanks unless ascites is

688
A TEXT-BOOK OF GYNECOLOGY.
present. The umbilicus remains normal. A vaginal examination
will reveal the pelvic origin of the tumor, and the fluctuation
wave can often be distinctly felt by the finger in the vagina. A
differentiating table is given on page 693. (v. Figs. 156 and 157.)
Broad Ligament Cysts.-A parovarian cyst gives rise to the
same area of dulness as does an ovarian cyst. Fluctuation is usu-
ally more distinct because of the thinner walls. Its more intimate
connection with the uterus, as is shown by vaginal examination,
together with the history of the case, will suggest its parovarian
origin. Papillomatous cysts of the broad ligament are differ-
entiated from ovarian cysts with much difficulty. Frequently
FIG. 156.
FIG. 157.
Y
AREA OF DULNESS IN OVARIAN CYST.
AREA OF DULNESS IN ASCITES.
they are closely incorporated with the uterus and are firmly
fixed low in the pelvis.
Encysted Dropsy of Peritoneum.-The intestines are
bound down by adhesions between which and the anterior
abdominal wall ascitic fluid accumulates. An effusion of
this kind makes its appearance suddenly, preceded, usually,
by a history of peritonitis. The abdomen, instead of being
prominent, is more or less flat. The area of dulness is un-
changeable. Fluctuation is limited.
DIAGNOSIS OF OVARIAN TUMORS.
689
origin.
Distended Bladder.-Distention from this cause is of recent
It is centrally located in the lower abdomen,
and, unless the result of paralysis, gives rise to much discom-
fort. It hardly seems possible that this condition could be mis-
taken for ovarian tumor, yet it has been. In all cases of doubt
the catheter should be passed.
Hydramnios.-Dropsy of the amnion sometimes complicates
pregnancy so that the amniotic fluid may be greatly in excess.
This condition, owing to the fact that the uterine walls are
usually very thin, and fluctuation more or less distinct, may
simulate an ovarian tumor. Ordinarily, a careful examination
will reveal the changes incident to pregnancy-softening of the
cervix, changes of the breasts, etc. The subjective symptoms
of pregnancy are rarely wanting. Hydramnios is frequently
due to albuminuria.
B. Fluctuating in Parts.
Ovarian Cyst, Multilocular.-The symptoms do not differ
from those resulting from a unilocular ovarian cyst, except that
fluctuation is much less distinct.
Ovarian Cyst with much Solid Matter.-May be either
benign or malignant. The constitutional symptoms depend upon
the character of the growth. It is exceedingly difficult to dif-
ferentiate this condition from a fibro-cystic uterine tumor. A
solid or semi-solid ovarian tumor is usually more mobile than is
a fibro-cystic uterine growth.
Fibro-cystic Uterine Tumor.-Is usually of slow growth at
first. It seldom occurs before the age of thirty, is com-
paratively rare, and usually gives rise to no emaciation. There
is menorrhagia more often than amenorrhea. Frequently the
lobulated surface of the tumor can be detected. Upon vaginal
examination it will be found continuous with the uterus, and
sometimes can be moved with it. Not infrequently the uterine
cavity is increased in depth.
Pregnancy (later stages).—So difficult is it at times to differ-
entiate between pregnancy and an ovarian cyst that I deem it
wise to add the following table, taken from Peaslee :—
44
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A TEXT-BOOK OF GYNECOLOGY.
Normal Pregnancy Five and a Half
Months or More.
Enlargement sudden and rapid; symmet-
rical, or inclined slightly to right side;
Features natural, healthy;
Superficial veins of abdomen not en-
larged. Edema of ankles not uncom-
mon after seven months;
Chest not conical;
Fluctuation not very distinct, unless much
liquor amnii;
Menstruation arrested;
Vaginal touch detects softening and ap-
parent shortening of the cervix, and
enlargement of the uterus;
Ballottement feels impulse of fetus;
Fetal heart-sounds detected;
Movements of fetus felt;
Enlargement of mammæ;
Umbilical areola in first pregnancy;
Has developed within six to nine months;
Follicles around the nipple equally de-
deloped in both mamma; become
white on stretching the skin;
Exception.—If fetus be dead, of course,
the movements and heart-sounds cease.
Ovarian Cysts, Second or Third Stage.
Enlargement gradual; asymmetrical till
in the third stage;
Features emaciated, anxious;
Veins are enlarged; edema in late stages,
from pressure;
Chest conical, if very great distention
Very distinct, especially in monocysts;
Not arrested till third stage has com-
menced;
No change in these respects; but uterus
is displaced, usually behind the cyst;
No result. Very rarely is imitated;
None;
None;
Occurs in exceptional cases only;
None;
Has developed within one to three years;
Unequally developed, and remain of the
same color as the areola.
C. Solid, no Fluctuation.
Solid Ovarian Tumor.-This may be either fibroma, car-
cinoma, or sarcoma. When malignant, cachexia, ascites, and
general symptoms of anasarca, which rarely if ever attend be-
nign tumors of the ovary, are prominent. These growths are
distinguished with much difficulty from pedunculated fibroid
tumors of the uterus, though usually they are more mobile than
the latter. There is an entire absence of fluctuation.
Fibroid Uterine Tumor.-If sessile, there is an intimate con-
nection between the uterus and the tumor, or the tumor is
evidently continuous with the uterus. Uterine fibroids are of
frequent occurrence, whereas solid ovarian tumors occur but
rarely. A uterine fibroid grows slowly, and is usually attended
by menorrhagia. There is tenderness in the lower abdomen
DIAGNOSIS OF OVARIAN TUMORS.
691
during menstruation. There is no fluctuation, and the uterus
moves with the tumor.
Pregnancy (earlier stages).-The well-known signs of preg-
nancy will of course be looked for. In determining the character
of the tumor the examiner will observe that upon bimanual it
is, if due to pregnancy, pyriform, symmetrical, and more or less.
resilient. The fundus of the uterus moves in harmony with its
lower portion.
2. A Tumor Distending Lower Part of Abdomen, not
Central in Position.
A. Fluctuating.
Renal Cyst or Retro-peritoneal Cyst in the Neighbor-
hood of the Kidney.-With renal cyst there is usually a history
of urinary troubles, with the occurrence every now and then of
pus, blood, or albumin in the urine. Nephritic colic, from an
impacted calculus, frequently precedes the formation of a renal
cyst. Edema of the lower extremities occurs early, and emacia-
tion late. The tumor is unilateral, commences in the lumbar
region, and grows forward and downward. The intestines lie in
front, instead of behind the tumor. There is clearly no connec-
tion between the pelvic organs and the tumor. Should aspira-
tion be resorted to, the fluid will contain urea, urates, and
chlorides. A large renal cyst is of rare occurrence.
Cyst of Omentum or Mesentery.—This is of exceedingly
rare occurrence. It chiefly occupies the middle line, though
seldom exactly median. Fluctuation is usually obscure, but
sometimes some degree of mobility is present. It is not con-
nected with the pelvis.
Hydrosalpinx (extreme cases).-Under this head may also
be included hematosalpinx and pyosalpinx. In rare instances
any of these conditions may give rise to an enlargement of the
Fallopian tube, which causes it to become abdominal. A dis-
tended tube is, however, usually confined to the pelvis, and is
detected only upon rectal and vaginal exploration. The tumor
is evidently closely connected with one side of the uterus. In
hydrosalpinx it is usually painless; though when the tube con-
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A TEXT-BOOK OF GYNECOLOGY.
tains pus or blood, pain is often a very prominent symptom.
Distention of the tube is ordinarily associated with menstrual
irregularities of some kind.
Cyst in Abdominal Walls.-This causes prominent bulging
of the parietes. It is rounded and is intimately attached to the
abdominal walls, following closely their movements. It gives
rise to dulness over the palpable area.
B. Solid.
Extra-uterine Pregnancy (tumor may be central).—An extra-
uterine pregnancy cyst may become solid after the death of the
fetus. The fluids are then absorbed and the tumor appears as a
hard, irregularly rounded mass, fixed in some part of the lower
abdomen or pelvis. It is intimately connected with the uterus,
which is always enlarged. The history should be carefully in-
quired into, for the symptoms elicited by physical examination
may closely resemble uterine myoma.
Scybala in Cecum or Sigmoid Flexure.-Fecal tumors are
seldom large enough to be mistaken for ovarian cysts. They
may occur in any part of the large intestine, and are usually pre-
ceded by a history of constipation alternating with colic and
diarrhea. They give rise, upon manipulation, to a peculiar
doughy feel, and ordinarily can be indented by pressure. As a
final test an effort should be made to thoroughly empty the
bowels.
A
Enlarged Spleen (extreme cases).-The conditions giving rise
to enlargement of the spleen sufficient to simulate ovarian tumor
are leucocythemia, cancer, syphilis, and amyloid degeneration.
Occasionally the enlargement may be great enough to extend into
the pelvis. It appears first under the left false ribs and extends.
downward and inward toward the middle line. The enlarged
organ, from its close contact with the parietes, gives rise on per-
cussion to absolute dulness over its entire surface. Sometimes
the characteristic notched border can be felt. Smaller splenic
tumors are slightly mobile. The constitutional symptoms attend-
ing the several affections responsible for the enlargement are
rarely absent.
DIAGNOSIS OF OVARIAN TUMORS.
693
3. Two or more Tumors Distending Lower Part of Ab-
domen.
Bilateral Ovarian Tumors (especially small dermoid cysts).—
A sulcus may be felt between them. In most instances, how-
ever, one tumor so completely overshadows the other that the
existence of the smaller one is not suspected until after the
abdomen is opened.
Hydatid Disease of Peritoneum.-Hydatid growths spring-
ing from the peritoneal surface, or, more frequently, from the
liver, often reach enormous proportions, and by distending the
abdomen may simulate an ovarian cyst.
A vaginal examination will show that the growth does not
have its origin in the pelvis. Percussion will locate the area of
dulness high up; fluctuation is more obscure and circumscribed
than in ovarian cysts, and frequently the so-called hydatid fre-
mitus can be felt. The tumor grows very rapidly from above
downward. If the diagnosis is doubtful a fine aspirating needle
may be introduced and the obtained fluid examined.
As a
rule it is perfectly colorless, transparent, of low specific gravity
(1007 to 1009), and alkaline or neutral in reaction, though
occasionally it may be acid. There are no organic substances.
Microscopical examination will reveal the characteristic hooklets.
CLASS II.-ABDOMEN DISTENDED-NO DISTINCT TUMOR.
1. Fluctuation Distinct.
Ascites.-The following table, taken from Peaslee, cannot be
improved upon in differentiating between ascites and large
ovarian cysts :-
Ascites.
Previous ill-health;
Enlargement comparatively sudden;
Face full, puffy, leaden;
Patient on back-enlargement is sym-
metrical, flat in front;
Patient on the side-flatness on sides;
Patient sitting up-abdomen bulges be-
low;
Large Ovarian Cyst.
Good health previously;
Enlargement gradual;
Face emaciated, peculiar;
Enlargement is not usually symmetrical,
never till third stage; prominent in
front;
No change of flatness;
Little, if any, change of abdomen;
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A TEXT-BOOK OF GYNECOLOGY.
Ascites (Continued).
Skin of abdomen, smooth, tense, shining;
On superficial view, abdomen very much
enlarged. Edema of extremities in all
cases, and, at last, of abdomen also;
Floating ribs not bulging;
Navel prominent and thinned;
More distinct in erect position;
Percussion gives a clear tympanitic sound
at highest portions of abdominal cavity,
in all positions. Is dull elsewhere, and
changes with the position; (v. Fig. 157.)
Aortic pulsation not felt through abdo-
minal walls;
Vaginal and rectal touch detect fluctua-
tion at once;
Uterus normal in size, mobility, and posi
tion; sometimes prolapsed;
Fluid a light straw-color; coagulates
spontaneously; contains albumin and
ameboid corpuscles;
Anemia supervenes early;
Hydragogues and diuretics produce tem-
porary relief;
Exceptions. If there be a very large ac-
cumulation, may be dulness at high-
est point of abdominal cavity-patient
being on the back; or the intestines
may be glued down; but deep per-
cussion may elicit tympanitic sounds;
one or both flanks may be clear, from
gas in the colon.
Large Ovarian Cyst (Continued).
Abdominal integuments natural, or
merely thinned;
Superficial view less enlarged. Edema
only in exceptional cases;
Chest conical from bulging of the false
ribs;
Navel not thinned;
More distinct in recumbent position;
Clear sound only at parts not correspond-
ing to the cyst, and in both flanks;
dulness over it in all positions;
(v. Fig. 156.)
Pulsations are transmitted through the
cyst to the abdominal walls;
Fluctuation less clear, and may not be
reached at all, or does not exist in case
of polycyst;
Uterus displaced behind the cyst, gen-
erally;
Fluid a darker shade; of various hues
in polycysts; abounds in albumin or
colloid matter; no ameboid corpus-
cles; never coagulates spontaneously;
Comes on late;
These remedies, as a rule, produce no
effect;
Exceptions. May be tympanitic sound
in cyst, if it communicate with intes-
tine; one or both flanks may be dull
from feces in the colon.
2. No Fluctuation.
Tympanites and Phantom Tumor.-It is this condition
which is responsible for so-called pseudocyesis, or spurious
pregnancy. The patient is usually hysterical and the condi-
tion is more apt to occur as she approaches the climacteric
period. The abdomen may be distended to the size of a preg-
nant uterus at full term, so that the existence of either pregnancy
or of a tumor of some kind is suspected. Frequently there is
DIAGNOSIS OF OVARIAN TUMORS.
695
an arching of the back which causes the recti muscles to become
tense, and which adds greatly to the confusion.
The examiner will observe that there is no fluctuation, nor do
the evidences of a solid tumor exist. If he can divert the
patient's attention by conversation or otherwise, relaxation of
the recti muscles will frequently take place, and the actual con-
dition be determined; or, if the patient be placed under the
influence of an anesthetic, the swelling will quickly and entirely
disappear, and the resulting flaccidity of the abdomen will per-
mit a thorough examination of its contents to be made.
When the patient believes the enlargement to be due to preg-
nancy her suspicions are based, not only upon the tympanitic
enlargement of the abdomen, but also upon the suppression of
the catamenia, which in the vast majority of instances is due to
physiological changes incident to the menopause. Usually the
patient is exceedingly anxious to become a mother, and the
mental condition is such as to cause her to exaggerate every
sign suggesting the possibility of pregnancy. The examiner
will also observe that the mammary glands are not altered and
that the uterus does not undergo the usual changes of preg-
nancy, the bimanual showing it to be of normal size and
perfectly mobile.
Obesity.-Obesity sufficient to give rise to abdominal en-
largement simulating an ovarian tumor occurs oftener at or
about the menopause. When associated with tympanitic dis-
tention the condition may greatly confuse the inexperienced
examiner.
It will be noted, on exploration, that the enlargement is
symmetrical. When the patient assumes the sitting or
upright posture the abdominal walls are thrown into pendulous
folds, the umbilicus remaining normally depressed. They can be
grasped between the two hands, when its great thickness will be
indicated. The sensation elicited by palpation is that of a doughy
enlargement which yields on firm pressure. The obesity is
general, involving the entire body—the face, limbs, breasts, etc.
Percussion will indicate resonance instead of dulness. It should
be remembered that deep percussing is necessary when the
abdominal walls are unusually thick.
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A TEXT-BOOK OF GYNECOLOGY.
Pendulous Abdomen.-Sometimes the abdomen becomes so
pendulous as to extend half way to the knees. The walls can be
grasped and pinched between the two hands, and there will be
an entire absence of all signs indicating either a tumor, ascites,
or pregnancy.
It will now be necessary, in order to make this chapter com-
plete, briefly to consider certain other conditions, with the diag-
nosis of which the abdominal surgeon should be perfectly
familiar, although they are not included in the schema studied.
Cancer of the Pylorus.-A tumor resulting from cancer of
the pylorus is small, hard, and movable, and is situated in the
epigastrium a little to the right of the median line. In its later
stages it becomes fixed. Pressure gives pain. The gastric
symptoms are always prominent.
Fibroid Thickening of the Pylorus.-This is felt as a local-
ized induration in the same location as the preceding condition.
It rarely reaches the dimensions of a tumor. It is extremely
difficult to differentiate this affection, during its early stages,
from cancer. Pressure upon fibroid thickening ordinarily causes
much less pain than is the case with cancer.
Morbid Growths of the Stomach.-These are, in at least
ninety per cent. of all cases, malignant—scirrhous cancer being
the form oftener attacking the stomach. If located on its poste-
rior surface, which is rarely the case, it may drag the stomach
downward as far as the umbilicus. Palpation causes pain.
The enlarged viscus is usually movable, at least not becoming
fixed until the later stages of the disease. The constitutional
symptoms are marked.
Molar Pregnancy.-The ordinary signs of pregnancy usually
exist, except that the abdominal tumor increases much more
rapidly than is the case in normal gestation, and the uterus
grows to a greater size. The enlargement will be recognized as
uterine, and sooner or later the characteristic discharge (p. 73)
will make its appearance.
Solid Growths of the Kidney.-These are carcinoma, ade-
noma, and the several varieties of sarcoma. Any one of these
conditions may give rise to an enlargement sufficiently great to
fill the whole abdominal cavity. They will be recognized by the
DIAGNOSIS OF OVARIAN TUMORS.
697
dulness produced on percussion over the lumbar region, which ex-
tends forward, by their fixity in the region of the kidney, and
by the urinary changes which are usually present.
Solid Growths of the Liver.-Usually cancerous or sarco-
matous. The tumor is oftener located in the right lobe. It will
be recognized as a solid resisting enlargement protruding from
under the ribs of the right side. Unless adhesions exist, the
liver will move upward and downward during respiration. In
cancer the characteristic knobs on the surface of the liver can
often be felt. The various malignant growths springing from
this organ are limited in size only by the capacity of the
abdomen.
Solid Tumors of the Gall-bladder.-Clinically, a gall-blad-
der distended with gall-stones, with thickened walls the result
of inflammation, is a solid tumor. The various malignant lesions
of the liver may also implicate the gall-bladder. The enlarge-
ment is located at the edge of the liver, and extends downward
and inward toward the umbilicus. The natural globular, ovoid,
or pear-shape of the gall-bladder is usually preserved. There is
more or less mobility in lateral directions. Absolute dulness
over the enlarged area rarely occurs.
Tumors of the Colon.-These growths are either adenoma,
adeno-sarcoma, or cancer. The adenomata are usually poly-
poidal in shape. In the vast majority of instances they are
found in the descending colon, are freely movable for some
inches in all directions, and seldom attain a size larger than that of
an orange. Cancer locates itself in any part of the large bowel,
and gives rise to an indefinable thickening, fixed or slightly
movable. When any of these growths are located in the sig-
moid flexure, it is possible to detect them by rectal exploration.
The intestinal excreta will often indicate the nature of the
growth.
Solid Growths of the Omentum.-Any of the forms of
malignant disease-colloid cancer being the most frequent-may
involve the omentum. Such growths give rise to a very irregu-
lar surface and are either hard, or boggy, depending upon
the proportion of colloid material present. Not infrequently
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A TEXT-BOOK OF GYNECOLOGY.
ascites exists with the disease. It is sometimes possible to
determine by palpation and deep percussion whether the growth
overlies the intestines.
Hematometra.-The tumor is clearly of uterine origin. It
is the result of retention of menstrual blood, caused by some
obstruction to its exit, located either at the cervix or in the vagina.
The menstrual blood does not make its appearance externally,
although all of the symptoms of puberty are present. The
symptoms of menstruation, minus the flow, recur at regular
intervals. The only symptom of pregnancy that exists is en-
largement of the uterus. The history, together with a physical
examination, will clear up the diagnosis.
Hydrometra. Occasionally an obstruction will occur in
the cervical canal after the menopause which gives rise to an
accumulation of watery fluid within the uterus great enough to
suggest an ovarian cyst. The uterine walls are sufficiently
attenuated to permit of fluctuation. The accumulation occurs
gradually. On physical examination the sound will locate the
obstruction and determine the cause of the enlargement.
Ovarian Abscess.-Ovarian abscess is usually located in the
recto-uterine pouch, on one or the other side, where it is adhered.
The tumor is rarely larger than a hen's egg, is obscurely fluctu-
ating, and very tender.
Distention of the Gall-bladder with Fluid.-The tumor is
fixed under the liver, is painless or slightly painful, and is pyri-
form or ovoid in shape. It may contain either bile, pus, or
water.
Nephric and Peri-nephric Abscess. It is not always pos-
sible to determine whether an accumulation of pus in the region
of the kidney has its origin in the organ itself or in its sur-
rounding structures. Indeed, the two conditions are usually asso-
ciated. If the suppurating process has continued for some time
there may be discoloration of the skin overlying the kidney,
with tenderness on pressure.
The evidences of fluctuation
are not always present. In case of doubt, aspiration can be re-
sorted to.
DIAGNOSIS OF OVARIAN TUMORS.
699
DIAGNOSIS OF SMALL OVARIAN TUMORS.
Ovarian tumors in their early stages may be confounded with-
Retroversion or retroflexion of a gravid uterus;
Small fibroid tumors of the uterus;
Pelvic hematocele ;
Pelvic cellulitis ;
Accumulation of feces in the rectum;
Tubal or extra-uterine pregnancy.
Retroversion or Retroflexion of a Gravid Uterus.-The
ordinary symptoms of pregnancy are rarely wanting. On physi-
cal examination the cervix will be found high up, and there will
be felt in the posterior fornix a softish, solid tumor, which
is continuous with the cervix uteri. Unless the fundus is
adhered it can be pushed out of the hollow of the sacrum by
placing the patient in the genu-pectoral posture, drawing the
cervix down with a volsella, and exerting pressure upon the
fundus either through the posterior fornix or the rectum.
Small Fibroid Tumors of the Uterus.-The ordinary signs
of pregnancy will be wanting. Upon bimanual the tumor will
be found intimately connected with the uterus, moving with it.
Menorrhagia is more frequent than amenorrhea. Usually it is
possible to palpate both ovaries, and thus determine their nor-
mal condition.
Pelvic Hematocele.-There will be a history of the sudden
formation of a tumor, with the usual symptoms of shock and
collapse attending hematocele. The tumor is oftener located in
the folds of the broad ligament, though it may be in the poste-
rior cul-de-sac. It is suddenly formed, and unless resolution
is interrupted by suppuration, gradually diminishes.
Pelvic celluli-
Pelvic Cellulitis.-There will be a history of inflammation,
followed by the gradual formation of the tumor.
tis frequently involves the ovary.
Accumulation of Feces in the Rectum.—The characteristic
pitting upon pressure will be detected. In all cases of doubt the
rectum should be flushed with a large enema.
Tubal or Extra-uterine Pregnancy.-The symptoms of
pregnancy may be present. An elastic tumor will be detected
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A TEXT-BOOK OF GYNECOLOGY.
in the region of one or the other Fallopian tube, present-
ing an obscure sensation of fluctuation. The uterus is enlarged
somewhat, frequently displaced, and the cervix is softened.
There is often a history of paroxysms of crampy, colicky pains
in the region of the tumor. Irregular hemorrhages from the
uterus are not infrequent. The decidua is usually expelled
during an attack of hemorrhage.
TAPPING FOR DIAGNOSIS.
The only circumstances under which tapping for diagnosis is
now justifiable is the existence of some intercurrent disease-
bronchitis, pneumonia, pleurisy, etc.—which is sufficiently severe
to counter-indicate ovariotomy, and which is made worse by the
pressure caused by the tumor; or the existence of great ascites
with a small tumor, when the presence of the tumor is doubtful.
It is, indeed, questionable if, in the latter condition, exploratory
incision in the hands of an experienced operator is not prefer-
able to tapping.
Those who maintain the advantages of tapping for the pur-
pose of diagnosis claim that it can do no harm, and that it is a
perfectly safe operation; that much information can be obtained
by an examination of the fluid; and that, should the cyst be
parovarian, the tapping will result in a cure, making laparotomy
unnecessary.
That tapping is a perfectly harmless operation is not in keep-
ing with the records of the past. Should the trocar penetrate a
solid fibroid tumor, or a malignant growth, fatal hemorrhage
may ensue. Inflammation and suppuration have more than once
followed tapping and aspiration. There is also danger of injur-
ing the intestines, it not always being possible to determine their
presence or absence between the tumor and the abdominal
parietes.
It is true that the fluid can be examined, and by it some idea
of the nature of the cyst determined. Unfortunately, however,
the character of the fluid obtained affords by no means positive
information as to the character of the tumor. In the first place, the
fluid may be of such a nature as not to pass through the trocar
or aspirating needle. Again, in multilocular cysts, the fluid, as we
DIAGNOSIS OF OVARIAN TUMORS.
701
have seen, is often very different in different loculi. Nor is the
fluid of any form of tumor sufficiently characteristic to afford
pathognomonic evidence of its nature. For instance, it is ex-
ceedingly difficult at times to distinguish the fluid obtained from
a parovarian cyst from that obtained from a simple unilocular
ovarian cyst. Finally, parovarian cysts are by no means always
cured by drawing off the fluid. It must be remembered, too,
that in most instances parovarian cysts are removed by ab-
dominal section with but little difficulty.
Method of Tapping.—Since this operation will occasionally
be called for, I will briefly describe the proper method of its
execution.
The trocar or aspirating needle should be absolutely clean.
If the quantity of fluid is very great, I think the trocar is prefer-
able to the aspirator. The bowels and bladder should be emptied,
and the patient placed at the edge of the bed upon her side.
The site of the puncture is thoroughly washed with a 1:1000
bichlorid solution. Four or five drops of a four per cent. solu-
tion of cocain are injected into the site of the incision, midway
between the umbilicus and the pubes, in the median line. This site
is the preferable one, unless previous percussion has determined
the existence of intestine underneath it. General anesthesia is
rarely called for unless the patient is extremely nervous. A small
incision is made through the skin with a sharp scalpel. A rubber
tube two or three feet in length should be attached to the tap-
ping trocar, the distal end being immersed in a pan of antiseptic
water, so as to prevent the entrance of air into the cyst
cavity. The trocar is then thrust into the tumor and the fluid
permitted to escape.
Previously to passing the trocar a many-tailed binder is placed
about the abdomen, and as the fluid is drawn off this should be
tightened. After the instrument is removed, iodoform is sprinkled
over the site of the incision, and a small pad of antiseptic gauze
applied, held in place by a strip of adhesive plaster. The patient
should be kept in bed for at least three or four days. In the
event of alarming reactionary symptoms the abdomen should
be opened at once.
CHAPTER XLVI.
OVARIOTOMY.
The General Principles of Abdominal Section.-In the
present chapter I shall consider the general principles of ab-
dominal surgery as applied to the various gynecological opera-
tions calling for abdominal section. This will save needless
repetition in dealing with those affections requiring removal of
the appendages for other causes, and removal of the uterus
wholly or in part.
The abdominal surgeon is compelled to work under many
difficulties which do not exist in ordinary operations.
His
manipulations are necessarily restricted, and he has to do with
organs which, though not in themselves essential to life, are in
close proximity to those which are. In many instances manipu-
lations within the abdominal cavity have to be done largely by
the sense of touch. It is rarely, if ever, possible to determine
positively the condition of the abdomen and its contents pre-
viously to an exploratory incision; and even after the abdomen
is opened the confusion is often very great. Again, no two cases
calling for abdominal exploration present exactly the same con-
ditions. It is, therefore, impossible to give set rules to govern
the operator in all cases. Only general principles can be dealt
with. Were one to dwell upon all the details covering the
many modifications which have been made in the past, an entire
volume would be required. The abdominal surgeon must, first
of all, be competent to contend with any contingency which
may arise from the tying of an artery deep in the pelvis to an
intestinal resection, or the removal of a kidney. He must, in
addition, possess tact, ingenuity, and coolness. These several
qualities are begotten only by extended study, observation, and
experience. To obtain them a perfect familiarity with the ana-
tomy of the abdomen is the first requisite; the second is an
equal familiarity with the various pathological changes liable
702
OVARIOTOMY.
703
to distort any of the pelvic or abdominal organs; and the third
and last, is a thorough knowledge of certain surgical principles
which are as broad as is surgery itself.
In the chapter devoted to antisepsis, I have dwelt in detail
upon the necessary preparation of the patient previously to ab-
dominal section. The reader, if he is a believer in antisepsis or
asepsis, is advised to study this chapter carefully. The prin-
ciples therein dealt with, must be observed before the patient is
placed upon the operating table. Unless the proper preparation
has been made, antisepsis, no matter how carefully carried out
after the operation is begun, will fail in its object.
When should Ovariotomy be Performed?-With few ex-
ceptions the proper time for ovariotomy is as soon as the diag-
nosis is made. Ordinarily there is nothing gained by delay. An
ovarian tumor will, in ninety-nine cases out of a hundred, run an
inevitably fatal course, unless its progress is interrupted by sur-
gical interference. It is true that, when the tumor is small and
still confined to the pelvis, it may continue indefinitely
without serious trouble resulting from its presence. The
various contingencies which have been studied-inflammation,
suppuration, adhesions, etc.—are, nevertheless, liable at any
time to arise. This is specially true of dermoid cysts. A
woman is, therefore, never safe while she is carrying an ovarian
tumor, and it is best to remove it as soon after its discovery as
is expedient.
It is not advisable to operate during menstruation if it can be
avoided. Formerly, the near approach of this function was con-
sidered an imperative counter-indication to immediate operative
interference. While it is probably best to set a day for the opera-
tion which anticipates menstruation for at least three or four
days, or which will correspond to the same length of time fol-
lowing its cessation, the observation of this precaution is now
looked upon as of much less importance than formerly. More
than once I have operated at the beginning of the flow, the ex-
citement incident to the operation bringing it on prematurely,
and I have never yet had cause to regret so doing.
Formerly, it was also considered unjustifiable to operate dur-
ing pregnancy. Pregnancy is, however, no longer a counter-in-
704
A TEXT-BOOK OF GYNECOLOGY.
dication to ovariotomy. On the contrary, early pregnancy com-
plicating a growing ovarian tumor makes ovariotomy all the
more imperative. The mortality attending the operation is not
greatly increased by the existence of pregnancy; nor does the
operation cause abortion even in the majority of instances. As
regards the mortality, Olshausen furnishes the following data: *
Up to the end of 1885 Schroeder had performed ovariotomy dur-
ing pregnancy in twelve cases, Tait in six, Sir Spencer Wells
in ten, and Olshausen himself in eight. But one patient of
the total of thirty-six died.
All authorities are agreed that it is best, if possible, to operate
previously to the fourth month. After this time the greater
turgidity of the pedicle, as well as of all the pelvic organs, makes
the operation more difficult.
The age of the patient is no bar to ovariotomy. The operation
has been successfully performed by Küster on a child eighteen
months old; it has more than once been successfully performed
on children six, seven, and eight years old. Young girls from
fifteen to twenty years of age are usually good subjects for the
operation.
As regards the other extreme, Bantock, Janvrin, Schroeder,
Miner and others, have made successful ovariotomies upon.
women from sixty-five to eighty-one years of age. Of course
great decrepitude, or the existence of organic disease, would
make the operation, in extreme old age, unjustifiable. There
is always a tendency for elderly patients to contract bronchitis
from undue exposure, or to suffer from hypostatic congestion of
the lungs. (Doran.)
Operating Table.-Any ordinary table of sufficient height
and narrowness will answer for this purpose. Its height should
depend upon the height of the operator-varying from three
feet to three feet eight inches. There is nothing more trying to
a tall surgeon than to work for a long time over an operating
table which is too low. A common, narrow kitchen-table, if
sufficiently strong, will answer very well. If not long enough,
one of corresponding height can be placed crosswise at its head.
* Doran "Gynecological Operations," p. 184, 1887.
OVARIOTOMY.
705
The table should be properly protected by clean quilts and a
sheet, over which is placed a mackintosh.
Clothing. The patient should be properly prepared for the
operation by being wrapped in warm blankets. It is sometimes
advisable, especially with feeble women, to protect the chest by
placing under the flannel jacket a layer of cotton-wool.
Preliminary Details.-After being placed upon the table and
the clothing properly arranged, the abdomen is exposed by re-
moving the antiseptic pad. A final scrubbing is given the abdo-
men with a 1 : 1000 bichlorid solution. The pubes is shaved,
if this has not been previously attended to, the parts are dried
with a sterilized towel, and the mackintosh sheet applied. This
is prepared by making an oval opening about seven inches long
by six broad, around the inner edges of which is spread adhe-
sive material. If the opening is of suitable size, it will fit
closely to the abdomen, leaving an exposed area extending from
the pubes to the umbilicus, six inches in width at its widest
point. The mackintosh will protect the clothing and leave the
patient perfectly dry and clean after the operation is concluded.
Over the mackintosh, as well as above, below, and at its sides,
are spread sterilized towels wrung from a I: 3000 bichlorid solu-
tion, so that all instruments used during the operation will come
in contact only with these towels.
Temperature of the Room.-Formerly, it was thought neces-
sary to operate in a room whose temperature was not less than
80°. This is sufficiently great to prostrate both the operator
and the patient. While it is not wise to operate in a temperature
under 60°, that of 70° is quite warm enough. The bodily tem-
perature of the patient can be maintained by proper clothing,
and the cooling of the peritoneum and abdominal contents can
be prevented by the application of soft, warm sponges and
cloths.
Arrangement of Instruments.-After the instruments have
been properly cleaned, they should be arranged in suitable trays
placed conveniently near the operator. It is best to have the
cutting instruments in one tray, and the blunt instruments, to-
gether with the hemostatic forceps, in another. The following
instruments and appliances will be required:-
45
706
A TEXT-BOOK OF GYNECOLOGY.
Three trays for instruments and two bowls for sponges;
Twenty small pressure forceps;
Six large pressure forceps;
Scissors bent on the flat;
Two stout scalpels;
Cleveland's ligature forceps;
Cyst or large pressure forceps, straight and elbowed;
Pedicle needle;
Long free needle with large eye;
Ovariotomy trocar and canula with tube;
Four sponge holders;
Six trocar-pointed needles threaded with No. 2 Chinese twisted
silk;
Twelve sponges (two or three of which are large flat);
Six glass drainage tubes of assorted sizes;
A piece of rubber dam, ten inches square, for drainage tube;
Dressings, including antiseptic cotton, adhesive plaster, and a
many-tailed binder;
A director for dividing the peritoneum.
In addition to the foregoing there should be conveniently at
hand an aspirator, a Paquelin cautery, a serre-nœud (Bantock's
modification of Koberle's), with pliers for fixing the wire, and
two Wilcox pedicle pins.
The Paquelin cautery is a great convenience; the serre-nœud
and transfixing pins are to be in readiness in case it is necessary
to deal with a fibroid tumor or with a solid ovarian tumor inti-
mately attached to the uterus. It is also well to be provided
with an elastic ligature sufficiently long to throw about the base
of the tumor, should the operation end in hysterectomy. I have
excluded from this list the wristlets and thigh belt recommended
by the English operators. Their application seems to me entirely
unnecessary, and I never yet have taken the precaution to secure
the wrists, or to apply a binder to the thighs during a laparot-
omy.
The instruments and sponges are all carefully counted before
the operation, and a record of their number made. This is very
important, for, unless the precaution be taken, there is danger
of leaving behind in the abdominal cavity, sponges or forceps
OVARIOTOMY.
707
which have been introduced for the purpose of controlling
hemorrhage.
Usually one assistant is all that is necessary, especially if the
operator has had extended experience. It is, however, wise to
have at hand a second assistant whose duty it is to aid the first
should complications arise calling for his services. In removing
very large solid tumors, the second assistant is often called upon
to support the tumor while the pedicle is being tied. He can
also hold the edges of the abdominal wound together while the
first assistant attends to the sponging and aids the operator in
securing the sutures.
Chloro-
formist
Table for
Patient's head
FIG. 158.

Senior
Assistant Receptacle
for fluid, under
Table for patient's body
O
Chief Junior
Nurse Assist.
table
Operator
Instrum
Trays
for ts
Spray
Window
of
Ward
Pans
for
Sponges
POSITION OF Tables, Operator, Assistants, etc., DURING OVARIOTOMY (Doran).
Fig. 158 will explain the proper position of all who take part
in the operation, as well as the proper arrangement of the tables,
the instruments, and the receptacle for the contents of the cyst.
Anesthetics. Unless the patient is suffering from bronchitis,
or from kidney lesion, ether is by all odds the preferable anes-
thetic.* Elderly patients with a tendency to bronchitis will
sometimes bear chloroform better.
Abdominal Incision.-After the patient is thoroughly anes-
thetized the operator takes from the tray four or five pairs of
catch-forceps (Fig. 159), a pair of elbowed scissors (Fig. 160),
* The urine should always be examined previously to the administration of ether.
708
A TEXT-BOOK OF GYNECOLOGY.
and a suitable scalpel. The catch-forceps he places upon the
sterilized towel above the field of operation so as to have them
conveniently at hand. There is a most decided advantage in
having the scissors elbowed. An incision is now made through
FIG. 159.

CP
G.TIEMANN & CO
тов
CATCH-FORCEPS.
G.TIEMANN & CO
FIG. 160.

ELBOWED Scissors.
the skin and superficial fascia of the median line, with one stroke
of the knife. The average length of this incision is three inches.
Spurting arteries are at once caught with the catch-forceps,
which are permitted to remain attached until after the peritoneum
OVARIOTOMY.
709
is opened; ordinarily a few minutes' compression will control
the bleeding from any vessel severed at this stage of the opera-
tion; it is rarely, if ever, necessary to resort to ligatures or tor-
sion. If the abdominal wall is much stretched by the tumor, it
is usually possible to make the incision between the recti muscles
so that the sheath of neither is opened into. This cannot be
so readily done when the abdominal walls are not stretched, as in
oophorectomy. While it is always desirable to reach the peri-
toneum without exposing the recti muscles, the abdominal wound
will heal quite as well should their sheaths be opened into. A
small area is next cleared from the subperitoneal fat, through
which the peritoneum is caught up by a pair of catch forceps
and pulled forward. A second pair of catch-forceps is attached
a short distance from the first, and a small puncture with the
point of a scalpel is made between them. The forefinger, or a
director (Fig. 161), is now inserted into the abdominal cavity,
FIG. 161.

G.TIEMANN & CO.
DIRECTOR FOR DIVIDING PERITONEUM.
the abdominal parietes lifted away from the tumor or the intes-
tines, and the peritoneum opened nearly as far as the skin wound
by means of the scissors.
I do not think it best to use the director before the peritoneum
is reached. It requires unnecessary time to look for the indi-
vidual layers and dissect carefully through them with the scalpel
and director. Experience will enable the operator to determine
by touch the thickness of the abdominal walls, when he can cut
directly down to the subperitoneal fascia with one or two strokes
of the scalpel. All bleeding points should be controlled before
the peritoneum is opened.
The length of the incision will necessarily depend upon the
nature of the operation. In oöphorectomy, and in thin-walled
unilocular cysts, it need not be over two inches. On the
other hand, it is sometimes necessary, in removing large,
solid growths to make the incision the entire length of the ab-
710
A TEXT-BOOK OF GYNECOLOGY.
domen. I cannot see the advantage of endeavoring to work
through too small an incision. To make it sufficiently large
to enable the operator readily to get at the contents of the
abdomen, when extensive intra-abdominal manipulation is neces-
sary, seems to me better practice than to work under the restric-
tions and embarrassments incident to a short incision. A long
incision does not in the least prejudice the prognosis.
Occasionally the tumor is so intimately adhered to the peri-
FIG. 162.

EMMET'S OVARIOTOMY TROCAR.
FIG. 163.
G.TIEMANN & CO.

GTIEMANN & CO.
SPENCER WELLS'S OVARIOTOMY TROCAR.
toneum as to make it difficult to distinguish the latter from the
cyst wall. More than once has the peritoneum been stripped
from the abdominal wall, the operator laboring under the im-
pression that he was removing the adherent cyst wall from the
peritoneum. The existence of such adhesions may be suspected
if the hemorrhage attending the abdominal incision is greater
than normal, or if the intramuscular fasciæ are of a deep pink
color. Ordinarily the operator will recognize that he is stripping
OVARIOTOMY.
711
the peritoneum by the deep red color of the underlying struc-
tures.
If there is ascitic fluid this should be permitted to escape as
soon as the peritoneum is opened, the assistant pressing upon both
flanks in order to force it out. Ascites is especially liable to exist
when there are cancerous or papillomatous growths within the
pelvis.
Intra-abdominal Manipulations.-An ordinary ovarian cyst
will be recognized after the abdomen is opened by its smooth,
FIG. 164.

G.TIEMANN & CO
WILCOX'S CYST FORCEPS.

FIG. 165
¿G.TIEMANN &COF
SPENCER WELLS'S CYST FORCEPS.
shining, white surface. The operator should now wash his hands
in sterilized water and make an exploration with his finger or
fingers. Should the intestines make their appearance, they are
kept out of the way by the assistant, who places sponges about
the tumor in such a way as to prevent their protrusion.
Tapping the Cyst.-After the cyst is exposed and the opera-
tor is reasonably sure of its nature, the tapping trocar (Figs.
162, 163) is thrust into it, and the fluid permitted to drain off.
712
A TEXT-BOOK OF GYNECOLOGY.
As the cyst wall collapses it should be seized with a pair of cyst
forceps (Figs. 164, 165), and pulled upward through the ab-
dominal incision. By doing this the intestines will be prevented
from escaping and the fluid from finding its way into the peritoneal
cavity. At this stage, should a piece of adherent omentum be
withdrawn with the cyst, an effort should be made to detach it
with the sponges; if this cannot be done it should be caught in
a pair of catch-forceps and its distal end divided. If the cyst does
not completely collapse, it is probable that it is multilocular.
After the large loculus is emptied the trocar is carefully thrust into
the smaller ones, thus emptying them one by one, if it is possi-
ble to do so. Sometimes the fluid will be too thick to pass
through the canula, in which event it will be necessary to with-
draw the canula and make an incision into the cyst large enough
FIG. 166.

GTIEMANN 500-
SPENCER WELLS'S T-FORCEPS.
to admit the hand. The edges of the opening in the cyst are
then grasped on each side with strong T-forceps (Fig. 166), the
hand introduced, and the contents scooped out.
If there are no adhesions, the cyst, after it is emptied, can be
drawn through the incision and its pedicle secured. If, on the
other hand, adhesions exist they must be dealt with according to
the methods presently to be described. The advantage of empty-
ing the cyst before undertaking to separate the adhesions lies in
the greater readiness with which adhesions can be treated and re-
sulting hemorrhage controlled. There is also less danger of
lacerating the intestines and other important abdominal and
pelvic viscera.
OVARIOTOMY.
713
Management of Adhesions.-In the management of adhe-
sions it is necessary to bring into action fingers, sponges, forceps,
scissors, and ligatures. Recent adhesions can ordinarily be
separated by the fingers alone, or by the use of sponges. On the
other hand, when they become firm their separation often taxes
the patience and skill of the operator to the utmost. Those
existing between the omentum and the tumor are the most easily
dealt with. If they cannot be separated by the finger or by
sponging, they may be caught between two catch-forceps and
divided; the proximal end can afterwards be tied with catgut.
Adhesions to the abdominal parietes can also be separated in
most instances by the use of sponges. In the worst cases, unfortu-
nately, this cannot be done, and they may be so firm as to make
it necessary to leave the cyst wall, or portions of it, behind.
Special care must be observed in separating adhesions from the
intestines, the liver, and the lower part of the pelvic cavity in
close proximity to the ureters and the large vessels. Long adhe-
sions may be first caught in catch-forceps, separated, and tied
after the cyst is removed. If there is much oozing of blood this
must be temporarily controlled by sponge-packing. It may be
necessary, before the abdomen is closed, to sear the parts with
the Paquelin, or to apply directly to the bleeding surface a
solution of iodin. The T-shaped forceps (Fig. 159) are exceed-
ingly useful in dealing with oozing of this kind. They may be
left on for five or ten minutes.
Treatment of the Pedicle.-In the past all sorts of methods
have been resorted to for the purpose of securing the pedicle.
It has been burnt off, crushed off, tied entire, tied in sections,
and secured in clamps and left outside of the abdomen to slough
away.
At the present time the methods of securing the pedicle have
practically resolved themselves into two-the clamp and cautery,
and the ligature. The mortality of ovariotomy dropped at once
when the extra-peritoneal method was discarded and the intra-
peritoneal adopted. In nearly all instances it is entirely possible
to deal with the pedicle so that it can be dropped into the peri-
toneal cavity.
Keith is the chief advocate of the clamp-and-cautery method,
714
A TEXT-BOOK OF GYNECOLOGY.
and in his hands it has reached its highest degree of perfection.
The clamp represented in Fig. 167 is first applied, and the tissues
of the pedicle crushed. The pedicle is severed about an eighth
of an inch from the clamp, after which the cautery is applied.
until there is left a" thin, gray, translucent band of anemic but
still living tissue." (Greig Smith.) The clamp is now removed,
and after making sure that all hemorrhage is controlled, the
pedicle is returned to the abdominal cavity.
Properly prepared silk is the ligature now almost universally
used for securing the pedicle. The size of the silk will vary
FIG. 167.

KEITH'S OVARIOTOMY CLAMP.
FIG. 168.
FIEMAN N=&
GTIEMANN & CO.

CLEVELAND'S LIGATURE FORCEPS.
according to the vascularity and size of the pedicle. It is not
necessary that it should be large, yet it should permit of suffi-
cient traction to secure the stump very firmly.
The ligature is made to transfix the pedicle by means of a
pedicle needle, or, better still, by means of Cleveland's ligature
forceps (Fig. 168). After the forceps transfixes the pedicle, the
blades are opened sufficiently to permit the assistant to slip into
them the loop of ligature; the blades are then closed and the
instrument withdrawn, bringing with it the double ligature.
The ligature can now be secured according to one of two
OVARIOTOMY.
715
methods. In the first method the ligature is cut in two, the two
ends thrown over each other so that when tied on either side
there can be no splitting of the pedicle. It is best first to secure
the ligature by a friction-knot; the tumor is then cut away, leav-
ing about half an inch of the pedicle above the knot. The
ligatures can now be tightly drawn and secured with a final
hitch.
•
FIG. 169.
The second method is that known as the Staffordshire knot,
first adopted by Lawson Tait. It is shown in Fig. 169. In
order to understand the method of making
this knot, let the reader pass a double string
between two fingers of his left hand. Throw
the loop of the string over the ends of the
fingers; then place one of the free ends.
under the loop and one over it. If the
two free ends are now tightened by a knot
he will find that the fingers, representing STAffordshire Knot.
the two sides of the pedicle, will be drawn
closely together. This is a very satisfactory knot, especially
for small pedicles. If the pedicle is very large and thick, I
prefer the first method. Should the pedicle be too large to
include in one loop, it may be transfixed in two or more places
and the several sections tied separately.
After the pedicle is secured, whichever method is adopted, it
is my practice to sear the surface of the stump with the
cautery. Perhaps this is an extreme precaution, but it is a
practice observed by many of the German operators. It is an
additional safeguard against hemorrhage, and there is less ten-
dency for the pedicle to contract adhesions after the cautery has
been applied.
The opposite ovary is now explored, and if there are any
evidences of disease this is also removed.
Cleansing the Peritoneal Cavity.—If no fluid has escaped
into the peritoneal cavity, and there have been no adhesions, all
that is necessary to do is to close the abdominal wound without
drainage. On the other hand, if the intra-abdominal manipula-
tions have been extensive and the oozing at all marked, or if
some foreign substance has escaped into the abdomen, especially

716
A TEXT-BOOK OF GYNECOLOGY.
septic fluid or colloid material, it is necessary to take every pre-
caution to cleanse the abdominal cavity most thoroughly before
closing it. There is no better way of accomplishing this than
by free irrigation, a procedure popularized by Keith and Tait.
A special apparatus, consisting of a siphon arrangement through
which the water is conducted into the abdominal cavity, has
been devised for this purpose. However, I think it is quite as
well to pour the water from a pitcher while the operator or his
assistant separates the abdominal wound with the two hands.
The abdomen is completely filled with the fluid, the intestines
being so manipulated as to wash away any septic matter or
débris which may have been left behind. The water is then
removed by pressing upon the flanks and forcing it out, and by
sponging. The washing is repeated as often as may be neces-
sary to remove the débris. If there is general oozing that cannot
be controlled by the ordinary measures, the abdomen may be
left filled with the sterilized water, which can be drawn off later
through a drainage tube. Warm water used in this way is also
exceedingly valuable in overcoming shock. I have seen patients
almost in a state of collapse rally quickly after its use. The
temperature of the water should be about 105° F.
way
Should none of the contents of the cyst have found their
into the abdominal cavity, it is only necessary to remove any
sponges which may have been placed in the abdomen during the
operation, and to clean the Douglas, and the lateral pelvic pouches.
This is best done by sponges attached to sponge holders or
long forceps. It is, to be sure, a good thing to leave the peri-
toneal cavity clean. On the other hand, it is entirely possible to
overdo the matter of cleansing it. There is no doubt that much
injury has been done in the past by the extreme measures re-
sorted to in completing the toilet of the peritoneum. Too much
rubbing and friction in the effort to remove every particle of
fluid will only cause unnecessary irritation. If the fluid that is
left behind is not septic, the peritoneum will absorb a reasonable
amount of it without either disturbing the system or prejudicing
the prognosis.
Drainage. The object of drainage is to remove the fluid
which the peritoneum secretes as a result of the irritation inci-
OVARIOTOMY.
717
dent to the operation, as well as to remove the products of the
oozing from sero-sanguinolent surfaces. The absorbing power
of a healthy peritoneum is very great, and in most instances the
fluid secreted is absorbed. However, it occasionally happens
that it is impossible to control all of the oozing of blood; or it may
be impossible to remove all of the foreign matter which has
found its way into the peritoneal cavity. It is, therefore, not-
withstanding modern antisepsis, frequently necessary to resort
to drainage, though the surgeon who practises antisepsis will
undoubtedly have less occasion to use drainage than the one
who does not.
It is not an easy matter to determine just when drainage is
indicated; hence, the maxim set forth by a well-known surgeon
is a good one to follow, viz.: "When in doubt, drain.”
I have, in Chapter XII, described the method of Mikulicz
FIG. 170.
FIG. 171.


G.TIEMANN &CO.
G.TIEMANN &CO.
THOMAS'S CURVED NON-PERFORATED THOMAS'S CURVED PERFORATED DRAIN-
DRAINAGE-TUBE.
AGE-TUBE.
of Vienna, who uses iodoform gauze for the purpose of packing
large bleeding or absorbing cavities in the abdomen, bringing
one end of the gauze out of the abdominal wound. The de-
odorant quality of the gauze prevents it from becoming offensive,
and it can be left in place for several days. Thus used, it not
only acts as a hemostatic but as a capillary drain as well.
When the object is not to control hemorrhage, but simply to
afford an exit for the fluid which gravitates into the cul-de-sac of
Douglas, glass drainage-tubes are preferable. Those shown in
Figs. 170 and 171 are the ones most commonly used. They are
nothing more than glass tubes open at both ends, the lower end
being perforated at its sides. The upper end is made funnel-
shaped so that it cannot slip into the abdominal cavity. Care
should be taken to select a tube sufficiently long to reach the
718
A TEXT-BOOK OF GYNECOLOGY.
bottom of the cul-de-sac of Douglas, while the flange rests
upon the skin surface; this prevents injurious pressure upon the
rectum. The tube is introduced either before or after the liga-
tures are passed. Douglas's pouch being the most dependent
part of the abdomen, the fluid gravitates into it and can be
drawn off through the tube. The upper end of the tube is pro-
tected by a sheet of rubber slipped over it, which should be suf-
ficiently large to enclose a sponge placed over the mouth of the
tube. A very simple device for drawing off the fluid is an or-
dinary glass syringe, to which is attached a piece of rubber tub-
ing long enough to reach the cul-de-sac through the tube. This
should be used every two, three, or four hours, depending upon
the quantity of fluid secreted. If not more than two drams of sero-
sanguinolent fluid are secreted during an interval of two or three
hours, the tube is no longer needed, and should be withdrawn,
after which the opening in the lower end of the wound is closed
by tying the provisional sutures, which were introduced for that
purpose.
*
Closing the Abdominal Wound.—After making sure that all
hemorrhage is controlled, the operator may proceed to close the
abdominal wound. Many plans for doing this are in vogue.
Some surgeons prefer to close the successive layers of tissue by
continuous catgut sutures, bringing the integument together by
interrupted silk sutures. The method most generally adopted
is the interrupted silk suture passed through all of the tissues—
peritoneum, fascia, and skin, or, peritoneum, fascia, muscle, and
skin, as the case may be. The surgeon should aim to have as
broad a union as possible. It is, therefore, best to include all of
the tissues in the sutures. About three sutures are inserted to
the inch. Before they are passed a large, flat sponge should be
placed over the intestines underneath the wound in order to
catch any hemorrhage that may result from the needle punctures.
I prefer the trocar-pointed straight needles for this purpose.
They readily penetrate the tissues, and no needle holder is re-
quired. After the sutures are all passed the ends on either side
* I have purposely described in this section the management of the drainage tube
throughout the after-treatment, although its consideration would more naturally come
under the latter head.
OVARIOTOMY.
719
are caught in catch-forceps. The surgeon now has the forceps
and sponges counted. He then removes the sponge which was
placed underneath the wound while passing the sutures, and
makes a final exploration to make sure that there has been no
hemorrhage. The omentum should next be drawn down and
spread out over the intestines. The assistant, unlocking the
catch-forceps attached to the ends of the ligatures, lifts the
abdominal wound by them. The wound is sponged with a 1 : 3000
bichlorid solution (no antiseptic is used within the abdominal
cavity), and the surgeon proceeds to tie the ligatures, beginning
at the lower end. If a drainage-tube has been introduced, the first
one or two ligatures are tied in a bow-knot, so that when the tube
is withdrawn the ligatures can be drawn tight and the opening
closed. Care must be taken not to produce too much tension
upon the sutures in tying. The irritation thus produced may
result in stitch-boil abscesses in spite of every antiseptic precau-
tion. After the edges of the wound are nicely coaptated, and
the sutures all tied, the latter are cut close to the knots by grasp-
ing all of them in one hand and quickly severing them, one by
one. Should the skin surface not be nicely coaptated, it can be
brought together by a continuous catgut suture.
Dressing the Wound at the Close of the Operation.
The mackintosh is now removed and the abdomen washed with
a 1:3000 bichlorid solution and dried with a sterilized towel.
Iodoform is sprinkled over the wound and a small strip of sur-
geon's silk applied. Over this is loosely placed a liberal supply
of iodoform or bichlorid gauze. Next a large pad of antiseptic
absorbent cotton is placed over the gauze. A many-tailed binder
is finally applied, which will, when firmly secured with safety
pins, support the abdomen and hold the dressings in place.
If a drainage-tube has been introduced, the dressings are nicely
fitted about the tube at the lower end of the wound. Care must
be observed not to permit the bandage to exert undue pressure
upon the tube; it should, however, be sufficiently tight to keep
the tube from being forced out should the patient retch. The
patient is now placed in bed and given in charge of the nurse.
The bed should be protected with a mackintosh and covered with
a drawn sheet arranged in several folds. The knees are supported
720
A TEXT-BOOK OF GYNECOLOGY.
by a pillow placed underneath them. If the operation is performed
in the room where the patient is to remain, all instruments,
appliances, tables, receptacles, etc., should be removed before the
patient recovers from the anesthetic.
In the foregoing description I have confined myself to ordi-
nary cases of ovarian cysts, where the adhesions, if present, are
not sufficiently extensive to prevent the removal of the tumor. I
have also presupposed the existence of a pedicle capable of liga- .
ture and management in the usual way. It now becomes
necessary to discuss the management of those cases where
no pedicle exists, or where it is impossible, because of extensive
adhesions or other complications, to remove the cyst wall.
Incomplete Ovariotomy.—Incomplete ovariotomy may end
in exploratory incision when the surgeon finds that, owing to the
complications before mentioned, or owing to the existence of
malignancy, it is deemed unwise to proceed further. He then
closes the wound, with or without drainage, as the conditions
suggest.
In other instances, he will, perhaps, have undertaken to
remove the cyst wall; but owing to the extensive adhesions, or
to the fact that the cyst is intra-ligamentary and cannot be
enucleated because of its deep attachment in the pelvis, he will
not dare to close the wound in the ordinary way. It is then
necessary to retreat in good order. All hemorrhage must first
be checked by securing the vessels on and within the tumor, as
well as those within the abdominal cavity. The surgeon, by
carefully inspecting all points that were adherent, must convince
himself that the intestines have not been injured. The abdom-
inal cavity is then cleaned as thoroughly as possible; if the
contents of the cyst have escaped into it, it may be necessary to
combine, with drainage of the cyst, abdominal drainage as well.
If the abdominal wound is longer than usual, its upper part
should be closed by sutures. The opening made in the cyst is
now enlarged and stitched to the walls of the incision, as is
shown in Fig. 172. The sutures are passed in such a way that
about a quarter of an inch of the peritoneum is brought in con-
tact with the cyst wall. After the sutures are tied the cyst will
be entirely cut off from the peritoneal cavity. This is the same

OVARIOTOMY.
721
method as that adopted in the management of extra-uterine
gestation cysts, which cannot be removed, and in the treatment
of pelvic abscesses. The surgeon should break down any septa
that may shut off loculi from the main cyst, and wash the cavity
with a weak carbolic solution, or with strong iodin. A drainage-
tube is finally placed at the most dependent portion of the cyst;
through this the cavity can be washed as often as is necessary
in order to keep it clean.
It is surprising how quickly a large cyst cavity thus treated
will contract and fill in with granulations. I have seen a large
FIG. 172.
INCOMPLETE OVARIOTOMY.
suppurating ovarian cyst, which contained nearly three gallons
of purulent matter, become completely obliterated in less than
two months' time following the operation.
Encapsulated Ovarian Cysts.-In studying the pathology
of ovarian tumors, it was shown that the cysts occasionally grow
down between the layers of the broad ligament. As the tumor
continues to enlarge it distends these layers and separates them.
I have seen a cyst of this kind dissect the anterior layer of the
broad ligament and the peritoneum nearly to the diaphragm.
46
722
A TEXT-BOOK OF GYNECOLOGY.
The capsule is, therefore, formed by the layers of broad liga-
ment. It is usually of a very pale red color, which contrasts
strongly with the white, glistening cyst wall ordinarily met with.
The parts are greatly disturbed by the cyst growing in this way.
Sometimes the cyst may burrow deeply enough to attach itself
to the pelvic fascia, when its close proximity to the ureters and
the large vessels makes these important structures exceedingly
liable to be injured.
It occasionally happens that there is sufficient space between
the uterus and the tumor to form a true pedicle, notwithstanding
the presence of the capsule; if so, the capsule can be removed
entire with the tumor. Unfortunately, this is rarely the case. In
most instances it will be necessary to enucleate the cyst from
the capsule. An effort is first made to brush or sponge the
capsule from the cyst wall as the latter is being withdrawn.
Sometimes the adhesions are so slight as to make it possible to
do this; oftener, however, it is necessary to incise the capsule
high up and to dissect it off with the fingers or with the handle
of a scalpel. During the dissection care should be observed not
to perforate or lacerate the capsule in any way.
When the hemorrhage proceeds from spurting vessels, these
must be caught and tied with fine catgut; or, should it amount
to nothing more than an oozing, it may be controlled by sponge
packing. As the enucleation proceeds, the base of the cyst is
finally reached at the deepest part of the capsule, when an effort
should be made to detach the cyst entirely. It is while endeav-
oring to detach the cyst at its base that the large vessels and
ureters are liable to be injured.
It is now necessary to care for the emptied capsule. Some-
times it is possible to constrict its base into a pedicle, when it is
transfixed, tied, and cut off, in the ordinary way. If, however,
the mass of tissue included in the ligature is at all great, its free
edges should be brought together above the ligature by a con-
tinuous chromacized catgut suture. If the base of the capsule
lies so deep in the pelvis as to make this method of treatment
impracticable, the capsule should be drawn through the abdominal
wound, the greater part of it cut away, and the remainder stitched
to the edges of the wound, as in incomplete ovariotomy (Fig. 172).
OVARIOTOMY.
723
Care should be taken to see that neither intestine nor omentum
protrudes through any openings in the capsule; indeed, such
openings should be entirely closed so that the interior of the cap-
sule is perfectly cut off from the peritoneal cavity. A glass
drainage-tube is now placed in the capsule. Finally, the peri-
toneal cavity is cleaned, and, if necessary, drained at the side
of the capsule, the principles of drainage already given being
observed.
It may be impossible to remove the base of the cyst from the
capsule. Indeed, it is sometimes necessary to leave portions of
non-capsulated cysts behind when the base is strongly adhered.
In instances of the kind, an effort should be made to remove as
much of the solid growth from the base left behind as is pos-
sible. It is hardly necessary to add that drainage is here im-
perative.
CHAPTER XLVII.
OVARIOTOMY (Continued.)
AFTER-TREATMENT-ILLUSTRATIVE CASES.
After-treatment.-The after-treatment of ovariotomies, or
laparotomies made for any purpose, cannot be properly carried
out without the coöperation of an intelligent nurse. There is
no class of nursing that requires greater skill than does the
nursing of abdominal cases. It has been said by a well-known
surgeon that the fate of every patient undergoing laparotomy is
determined before she is removed from the operating-table, but
to this statement I cannot entirely agree. The best directed
efforts of the surgeon may be defeated by the ignorance or
the wilful neglect of the nurse. This is especially true if a
drainage-tube is used; so long as the tube is in situ the abdomen
is exposed to contamination from without. The most rigid anti-
sepsis may have been observed by the operator and his assist-
ants and yet the abdominal cavity may be infected through im-
proper care on the part of the nurse. She should, therefore, first
of all, be thoroughly familiar and in sympathy with the details of
antisepsis. She should know how to use the catheter and the ice-
cap. She should be perfectly capable of taking the pulse and the
temperature. She should know how to prepare and administer
nutritive enemata. She should be able to empty the drainage-
tube as often as may be necessary. She should keep an accu-
rate clinical record, to which the surgeon can refer at each visit.
She should be able to recognize symptoms of shock, collapse,
and internal hemorrhage. And, finally, she should possess suf-
ficient moral courage rigidly to adhere to the surgeon's direc-
tions, despite the pitiful appeals which patients often make for
cold water or unlimited quantities of ice.
Notwithstanding the numerous requirements indicated in the
foregoing, the after-treatment of an ordinary case of ovariotomy
724
OVARIOTOMY-AFTER-TREATMENT.
725
consists mainly in not doing certain things which are harmful.
After the patient is placed in bed she should be kept as quiet as
possible until she returns to consciousness. The bed should be
previously warmed by means of a warming-pan or hot water-
bags; but the latter should be removed before the patient is
placed in bed. Unless this is done there is great danger of
burning her. It has been my misfortune to have had several
patients, while under the influence of anesthetics, severely burned
by hot water-bags or bottles. No matter how emphatically the
nurse is cautioned regarding their use, they are liable to come
in contact with the skin surface and do harm. I have, therefore,
discarded them entirely, except for the purpose of warming the
bed previously to transferring the patient to it.
If the patient has been properly dieted for the operation,
vomiting may not be excessive. Ordinarily, however, vomiting
will continue with more or less persistence for the first twenty-
four hours following the operation. The patient will also com-
plain, in most instances, of intense thirst. Cold water will
aggravate both the vomiting and the thirst; consequently, nothing
but hot water should be given, and that in small quantities and
as hot as the patient can sip it. It is worse than useless to under-
take to force nourishment while there is irritation of the stomach,
for the vomiting will only be aggravated by it. Should vomiting
persist, relief may be obtained by washing the stomach with a
glass of warm (not hot) water, and encouraging the patient to
eject it at once; more or less bilious matter will be thrown off
with the water.
If the patient cannot tolerate the hot water, and the thirst is
marked, it may be ameliorated by an enema consisting of a pint
of warm water, to which may be added, in case the tympanites is
distressing, a few drops of turpentine. The water in the rectum
is absorbed, and the intense thirst more or less relieved.
Stimulants are counter-indicated unless to overcome serious
shock and collapse. They may then be used in the form of
hypodermic injections of brandy, or as enemata. If administered
hypodermatically, a dram of brandy or the best rye whiskey may
be used at each injection, and as often as is necessary; if admin-
istered per rectum two ounces of brandy in a pint of warm water
726
A TEXT-BOOK OF GYNECOLOGY.
should be thrown into the lower bowel. In the event of heart
failure, hypodermic injections of strychnia sulph., digitalin,
strophanthus, or glonoin, may be resorted to. In addition to
the foregoing, the general measures useful for overcoming shock,
under whatever circumstances it occurs, should be applied.
The external application of warmth, friction of the body, lower-
ing the head, cloths wrung from hot water applied to the pre-
cordial region—any or all of these measures may be brought
into requisition if necessary.
If the patient can urinate spontaneously, she is permitted to
do so from the very first; if not, the catheter must be used
as often as every six hours. (v. Chapter XII). After twenty-
four hours, if the vomiting ceases, small quantities of nourish-
ment may be given. It should at first be of the blandest
character. A good article to begin with is crust coffee, in
teaspoonful doses every hour, increasing the amount hour by
hour, if the stomach will tolerate it. In the course of eight or
ten hours a tablespoonful of kumyss, weak beef tea, or milk
with lime water, may be substituted for the crust coffee. The
patient's condition does not call for nourishment during the
first twenty-four hours following the operation. Even if it is
not ejected by the stomach the system will rarely assimilate it
in any quantity and more harm than good follows its adminis-
tration. Usually patients are not hungry, and symptoms of
prostration, should they supervene, are best overcome, not by
food substances, but by stimulants.
Unless a drainage-tube has been introduced, the patient
should be permitted to lie in the position which affords her the
most comfort. She should not, however, be permitted to throw
herself about in the bed. When she turns it should be with the
help of the nurse. She should be encouraged to lie in one
position at least an hour at a time.
If the case runs a normal course, there should be no rise
whatever in the temperature or pulse. The amount of pain is
ordinarily much less after the removal of large ovarian cysts
than it is after oophorectomy. The bowels should be moved
on the third day by an enema. The dressings should be
changed on the seventh day, at which time a part of the stitches
OVARIOTOMY-AFTER-TREATMENT.
727
may be removed. It is usually best to leave behind every other
suture for a couple of days longer, though, if there are evidences
of irritation, all should be removed at once. After the stitches
are removed, it is well to support the edges of the wound for a
week or ten days with strips of adhesive plaster, around which
the abdominal bandage is placed.
It is quite safe for the patient to sit up in bed on the fourteenth
day; and it is entirely possible for her to get out of bed, even
after most severe operations, on the sixteenth or eighteenth day
without serious risk. At the end of the twenty-first day, or, if
she does not gain strength rapidly, at the end of the twenty-
eighth day, she may return to her home. She should be in-
structed to wear an abdominal supporter or bandage for at least
six months. Unless this precaution be taken there is danger of
hernia resulting from stretching of the cicatrix.
Such is the course which a normal case of ovariotomy, in these
days of antisepsis, will run, in perhaps the majority of instances.
The reader must not, however, imagine that every case will ter-
minate so favorably and give rise to so little anxiety. Certain
complications are liable at any time to arise, and this chapter
would be incomplete did they not receive consideration.
The Pulse and Temperature.-While, as has been intimated,
the pulse and temperature should remain normal, they frequently
become perverted, even markedly so, without interrupting the
favorable progress of the case. Thus, it is not uncommon
for the temperature to rise a degree, or even two degrees, during
the first two or three days succeeding the operation. This
is usually due to the absorption of fluid which is either left
behind, or is poured into the abdominal cavity because of the
peritoneal irritation attending the operation. I have more than
once known the temperature to rise in this way without any other
evidence of peritonitis, pain being absent, and the patient suffer-
ing not the least inconvenience. If, however, the rise in tempera-
ture is associated with pain in the bowels of a sharp lancinating
character, and with other symptoms indicating peritonitis, it is, of
course, significant, and requires especial attention.
The pulse, too, may become perverted without a correspond-
ing rise in the temperature. I have known it to be as high as
728
A TEXT-BOOK OF GYNECOLOGY.
140° for three or four days following the operation, while the
temperature remained perfectly normal. In all of my cases where
this occurred, convalescence was uninterrupted, the pulse-respira-
tion ratio becoming normal in due time. It is difficult to explain
the very great rapidity of the heart's action in instances of the kind.
Possibly the shock attending the operation, although not mani-
festing itself in other ways, so affects the inhibitory apparatus of
the heart as to permit the latter to run away with itself; or, as
suggested by Mundé, it may be due to purely mental causes. At
any rate, this disparity between the pulse and the temperature no
longer alarms me when the patient seems to be doing well in
every other respect. If the temperature is subnormal with a
pulse of this kind, the disparity is usually due to septic peritoni-
tis. Septic peritonitis, however, impresses the system so pro-
foundly that other symptoms of this most dangerous complica-
tion stand out prominently.
Tympanites.—This is a frequent and distressing complica-
tion; it is ordinarily an expression of peritonitis, though flatu-
lency may occur without inflammation. When not a feature of
peritonitis, it is due to the disturbance of the intestines during
the operation, and to the diminished intra-abdominal pressure re-
sulting from the removal of large growths. The indicated remedy
-colocynth, china, lycopodium, bryonia, etc.-will often afford
most decided relief when more radical measures are not called
for. If relief is not afforded by internal medication, a rectal tube
should be passed which will often permit the gas to escape. If
the latter expedient fail, turpentine or peppermint enemata
may be tried. Finally, if these several measures are unsuccessful,
the existence of peritonitis is probable, in which event the saline
cathartics should at once be resorted to.
Septicemia and Peritonitis.-I include these two complica-
tions under one head, for the reason that peritonitis, in by far the
larger number of cases, is due to septicemia. The fact that a
slight increase in temperature not infrequently supervenes after
laparotomies has already been noted. If this rise be due to
the absorption of a limited amount of fluid, or even septic
matter, the system is perfectly able to eliminate the poison,
and the case will progress to a favorable termination; in
OVARIOTOMY-AFTER-TREATMENT.
729
obstetric parlance this is nothing more than a slight septic in-
toxication.
On the other hand, if germs have found their way into the
abdominal cavity during the operation, or if septic matter has
been left behind in such quantities, and of such a character, as
profoundly to impress the system, the surgeon will have to con-
tend with the double complication of septicemia and peritonitis.
These complications usually manifest themselves during the first
few days following the operation; rarely do they appear after the
seventh day. If the convalescence has progressed normally for
the first five or six days, the sudden rise in temperature is usually
due to causes other than septicemia.
The symptoms of septicemia and peritonitis are: a high tem-
perature, pain, tympanites, vomiting, and prostration. Some of
these symptoms usually stand out more prominently than others.
The tympanites and vomiting are particularly obstinate. There
is something more than a simple elevation in the infra-sternal
region which may be present in perfectly normal cases. The
distention of peritonitis is "drum-like," and it may be sufficiently
great to interfere with respiration.
If the frequent association of the two affections, septicemia and
peritonitis, was fully comprehended by the surgeon of even ten
years ago, certainly the treatment was conducted upon the
most unscientific principles. The practice of administering
opiates, then in vogue, is now deprecated by surgeons of all
schools. In their stead the saline cathartics are used. This
practice was, I believe, inaugurated by Tait, and it is one of the
most satisfactory procedures in abdominal surgery.
As soon, therefore, as symptoms of septicemia and peritonitis
present themselves, an effort should at once be made to move
the bowels with a saline cathartic. A seidlitz powder.may be
given, and repeated in the course of four hours if the first does
not produce the desired result. If the stomach is irritable, as it
usually is, it is best to give the dissolved powder in small quan-
tities at intervals of five minutes. Should this fail, small doses of
calomel may be given in 1-10 grain tablets every half hour until
fifteen or twenty are taken, followed by teaspoonful doses every
half hour of Rochelle or Epsom salts, until four or five doses are
730
A TEXT-BOOK OF GYNECOLOGY.
taken (Mundé). The action of the cathartic may, if necessary,
be supplemented by enemas of oil or ox-gall. The cathartics are
purely eliminative in their action. The free movement of the
bowels will ordinarily relieve the tympanites, the vomiting, and
the high temperature.
If the bowels remain obstinately closed in spite of the cath-
artics and enemas, there is probably an intestinal obstruction,
and no time should be lost in reopening the abdomen and
seeking the cause of the obstruction. It is true that this is a
most desperate procedure, for, no matter how simple the primary
operation may have been, it is quite a different thing to open
the abdomen with the intestines enormously distended with gas.
After the obstruction is overcome, the intestinal distention should
be relieved by making, with a fine hypodermic needle, numerous
punctures into them, through which the gas is permitted to
escape. The intestines are then returned to the abdominal
cavity, the abdomen is washed with sterilized water in which the
intestines are left floating, and the abdominal wound reclosed.
A drainage tube under the circumstances is imperative.
If the vomiting persists, the stomach must be given absolute
rest by administering all nourishment through the rectum. The
rectal food should be given in such a form as to produce the
best possible results with a minimum of disturbance. This
object is attained by using food which has been previously
digested and which possesses great nutritive properties. A
favorite nutrient enema of mine is half an ounce of bovinin and
four ounces of peptonized milk, to which may be added, if indi-
cated, an ounce of brandy. This should be repeated every four
or six hours, as the exigencies of the case demand.
This chapter would be incomplete without a list of the homeo-
pathic remedies oftener used in contending with the conditions
and complications described, together with their indications.
I have so often seen good results follow the administration of
properly selected remedies in the conditions dealt with, as to
make me confident that the abdominal surgeon who does not
use them is depriving his patient of most valuable agents. I am
also sure that the homeopathic surgeon will be compelled to
resort to opium much less often than will the surgeon who is un-
OVARIOTOMY-AFTER-TREATMENT.
731
familiar with the specific action of the remedies whose indications
I give. However, nearly all surgeons now restrict opium, in the
after treatment of laparotomies, to those cases where the pain
and restlessness are so great that it is utterly impossible to keep
the patient quiet without its aid. It is then best administered in
the form of hypodermic injections of morphia.
Therapeutics.
Colocynth.-Abdomen distended and painful; great tympani-
tes; incarcerated flatus; cramp-like pain in both sides of abdo-
men; severe colicky pains, mostly around the navel; great rest-
lessness and loud screaming on change of position; relieved
by drawing knees up.
Bryonia.-Griping pains about the navel; constant painful
cutting pains in the intestines, with the feeling as though some
one were digging her with the fingers; great sensitiveness of
abdomen; ALL SYMPTOMS AGGRAVATED BY THE SLIGHTEST MOTION.
Belladonna.-Distention of abdomen; the transverse colon
protrudes all the way across the abdomen from incarcerated
flatus; loud rumbling and pinching in the abdomen; SHOOT-
ING, DARTING, CUTTING PRESSURE IN HYPOGASTRIUM; tenderness
even to slight pressure, especially over ovarian region; CEREBRal
EXCITEMENT.
Arsenicum.-Rumbling in bowels; violent pains in abdomen,
with great anguish; frequent hiccough, with constant nausea and
vomiting; ineffectual retching; VOMITING IMMEDIATELY AFTER
EATING OR DRINKING; intense thirst; great restlessness; SYMP-
TOMS OF SEPSIS.
Hypericum.-Especially indicated in nervous patients who
suffer a great deal of pain, without inflammatory symptoms; tym-
panitic distention of abdomen; cutting in belly in region of
navel; stitches in small of the back; ACHING PAIN AND SENSATION
OF LAMENESS IN SMALL OF BACK; jerking and twitching of the
limbs; DYSURIA.
Coffea.-Sleeplessness; fear of death; pain seems unendura-
ble; colic, as if the stomach had been overloaded; cannot suf-
fer the clothes to be tight over the abdomen; continuous pinch-
ing pain in the iliac region.
732
A TEXT-BOOK OF GYNECOLOGY.
Lycopodium.-Spasmodic contraction in the abdomen;
colicky pain in the right side of the abdomen extending into
the bladder, with frequent urging to urinate; ACCUMULATION OF
FLATUS, WHICH BECOMES INCARCERATED; great fermentation in the
abdomen, with rumbling; discharge of much flatus per anum;
deposits of uric acid in urine.
China.-Distention of abdomen with griping, and here and
there a sharp pain; MUCH FLATUS, WITH RUMBLING; emission
of flatus; especially useful after the loss of a large amount of blood,
with dyspnea, ringing in the ears, etc.
Nux vomica.-Pressure under the short ribs, as from incar-
cerated flatus; colic, with pressure upward, causing dyspnea,
and downward, causing urging to stool and urination.
Ipecacuanha.-Constant NAUSEA, WITH RETCHING; vomiting
of ingesta, and then of bilious matter; flatulent colic, with fre-
quent stools; cutting about the umbilicus.*
Illustrative Cases.
It is my object to present, in the following series of illustrative
cases, such only as are typical of certain conditions and com-
plications dealt with in the text.
•
CASE LXXVI.—Ovariotomy for Ruptured Cyst. Recovery.-Patient, American,
æt. 46. Referred to me by Dr. W. A. Winslow of Sylvania, Ohio. Married for 25
years. Four children; labor normal in all instances. Had always enjoyed good
health up to a year before entering the hospital (October 3, 1892), at which time
menstruation ceased. The menses were suppressed until the following August, when
there was a slight flow. During the suppression she was free from headache, flashes
of heat, and all of the usual symptoms attending the menopause.
About three months before coming to the hospital she noticed for the first time an
enlargement in the right groin, which grew very rapidly, the abdomen becoming
greatly distended. Some four weeks before entering the hospital her husband, dur-
ing sleep, struck the abdomen with his elbow. This was followed by severe and
intense pain, with the symptoms of shock and collapse. The temperature immediately
rose to 103°, and for two weeks she was confined to her bed with peritonitis. She
entered the hospital October 3, 1892. The tenderness and abdominal pain were at
that time most distressing. The temperature ranged from 100° to 102°.
On October 11th the abdomen was opened. The cyst wall was so intimately at-
tached to the anterior abdominal wall that it was unavoidably incised. The sac was
adherent to the entire anterior and lateral abdominal parietes, though the adhesions,
* v. Therapeutics of Acute Inflammatory Affections of the Pelvic Organs.
OVARIOTOMY-ILLUSTRATIVE CASES.
733
being of recent origin, were separated by the fingers and by sponges with no great
difficulty. There was much oozing from the site of the adhesions, which was con-
trolled by sponge packing. A large quantity of ascitic fluid was within the abdominal
cavity. The pedicle was easily secured and cut away; after which the abdomen was
thoroughly washed with sterilized water, a drainage tube inserted, and the wound
closed.
The temperature immediately dropped to normal, and remained so throughout the
convalescence. There was no shock following the operation. The drainage-tube
was withdrawn on the second day; the stitches were removed on the seventh; the
patient sat up in bed on the tenth, and was discharged perfectly well on November
3d, just one month from the day she entered the hospital and three weeks from the
date of the operation.
CASE LXXVII.-Large Unilocular Ovarian Cyst, with Hemorrhage into its In-
terior. Great Rapidity of Pulse following Operation without Corresponding Rise in
Temperature. Recovery.-Patient æt. 23. Referred to me by Dr. Young of Pioneer,
Ohio. She entered the hospital on April 29, 1892. Two years previously to that time
the abdomen began to increase in size. For fourteen weeks before entering the hospital
the enlargement was uniform, centrally located, and was so large as to cause marked
difficulty in breathing when lying down. The menses continued normal and her gen-
eral health was not seriously compromised, though pressure symptoms had begun to
manifest themselves.
The abdomen was opened on May 3d. The contents of the tumor were drawn
off through a trocar and were of a peculiar grumous character, probably the result of
hemorrhage into the interior of the cyst. There was but one cyst, and its collapsed
wall was drawn through the abdominal wound with perfect ease. After securing the
pedicle, the abdomen was closed with six interrupted sutures and the patient placed
in bed.
The tumor and its contents weighed thirty pounds. The temperature never rose
ábove the normal, though the pulse for three days succeeding the operation varied
from 120 to 140. After this time it gradually dropped to normal. The sutures were
removed on the seventh day, and the patient left the hospital three weeks from the
day of the operation.
CASE LXXVIII.—Intra-ligamentary Cyst, Dissecting the Peritoneum in front as
far as the Liver. Complete Enucleation of Cyst. Death.-Patient æt. 32. Referred
to me by Dr. H. M. Warren of Jonesville, Michigan. Nationality, English; married.
Entered the hospital on December 15, 1891. She began to menstruate at fourteen, at
which time the menses were scant and recurred every two weeks, becoming regular
at 21. Two years before entering the hospital she had typhoid fever, and for seven
months following this attack she suffered from symptoms of malaria. Was married
one year previously to consulting me. Two weeks before marriage she had a severe
bearing-down pain in the uterus which continued after marriage. There was much
pain in the bowels, with a feeling of distention.
Had one miscarriage at the fourth month, which occurred in March. Flowed for
ten days after the miscarriage. Had much leucorrhea, which was yellow and very
excoriating. Had much pain around the left side of the body from the spinal column
to the umbilicus. Appetite was poor and emaciation great; the bowels were regular.
734
A TEXT-BOOK OF GYNECOLOGY. -
The abdomen was extremely enlarged and the ordinary symptoms of fluid confined
within a cyst presented themselves.
The operation was performed January 12, 1892. Upon exposing the cyst,
instead of the smooth, glistening surface which is characteristic of ovarian cysts, its
surface was very red and was covered with large vessels. The contents were fluid
and readily passed through the tapping trocar.
After the cyst was emptied it was found firmly fixed at its base. An incision was
made into the capsule and the enucleation extended to the base of the broad ligament
below and to the lower border of the liver above. There was much bleeding, which
was controlled with difficulty by sponge packing and ligatures. I succeeded, however,
in completely enucleating the cyst, when there was left behind an enormous cavity.
The capsule was tied in sections and removed, its edges being brought together with
continuous catgut sutures. A strip of gauze was placed in the lower end of the capsule
and left projecting from the abdominal wound. Weight of cyst and contents, fifty
pounds. Time of operation, two hours.
The patient was removed from the operating table suffering greatly from shock.
The temperature very soon began to rise, and on the following day it was evident that
the gauze was not draining the cavity as it should. This was removed and a drainage
tube inserted. The temperature gradually increased, prostration became more and
more marked, and death occurred on the sixth day from sepsis. A subsequent exami-
nation showed that the cavity left behind was not thoroughly drained. The mistake
was, undoubtedly, in not stitching the emptied capsule to the abdominal wound and
packing the cavity with gauze. I hoped to avoid the prolonged convalescence neces-
sarily attending the healing by granulation.
CASE LXXIX.-Large Proliferous Cyst Weighing Forty Pounds. Convalescence
Uninterrupted.-Patient æt. 46. Referred to me by Dr. Byron Deffendorf of Fowler-
ville, Michigan. Began to menstruate at seventeen; flow was normal and painless.
Married at seventeen. Has had four children; labors all easy and natural. Had been
troubled for a number of years with occasional severe attacks of pain in the stomach
which seemed to be caused by indigestion.
About four years before consulting me she noticed a growth in the left side which
gradually increased in size. The menses were regular and painless but scant.
Bowels were regular. The abdomen was enormously distended, and the pressure
symptoms distressing.
The abdomen was opened on February 20, 1891. The cyst was multilocular and
proliferous. It was necessary to incise the cyst wall, introduce the hand, and break
down the smaller cysts. The adhesions were not extensive and the collapsed cyst
was withdrawn through the abdominal incision without difficulty. The left ovary had
undergone cystic degeneration and was about as large as a hen's egg. This was re-
moved, a drainage-tube introduced, and the abdomen closed by interrupted silk
The temperature did not rise above the normal, and the patient left the
hospital on March 12th, twenty days after the operation.
sutures.
CASE LXXX.-Large Fibro-cystic Tumor of the Ovary, with Long Pedicle, giving
rise to Enormous Distention of the Abdomen from Ascitic Accumulation. Operation.
Recovery.-Patient æt. 39. Referred to me by Dr. L. S. Morris of Lee's Corners,
Michigan. Menstruated at 14; was not regular and has always had more or less
dysmenorrhea. Married at 15. Has had seven children, the eldest being 21 and the
OVARIOTOMY-ILLUSTRATIVE CASES.
735
youngest 8 years of age. The last labor was very severe, after which she had puer-
peral fever, being confined to her bed for fifteen weeks. Five weeks following the
last labor she noticed for the first time a tumor in the left lower abdomen. This con-
tinued for about a year and then disappeared for two years. At the time of entering
the hospital she complained of much pain in the vertex, and constant backache. The
appetite was good.
A physical examination revealed a large, solid tumor in the lower abdomen which
was mobile and seemingly connected with the uterus. There was at the time of the
first examination no ascites. The tumor caused much distress because of the pres-
sure upon the rectum, giving rise to hemorrhoids and constipation.
As immediate operative interference did not seem imperative, and as the University
Hospital was about to close for the summer vacation, the patient was sent home to
return in the fall. In the following October she reentered the hospital. The abdomen
had, during the interval, increased greatly in size and the patient was much distressed
in various ways. Upon examination there was found a large, solid tumor floating in
fluid. It was entirely possible to practise abdominal ballottement. While lying upon
the back, the tumor, if suddenly pressed downward, would float upward and strike
the abdomen with a distinct choc en retour. It was surrounded by a tympanitic
corona produced by the intestines floating upon the ascitic fluid.
The diagnosis was somewhat uncertain. Owing to the large quantity of ascitic
fluid I feared malignancy. The general health, however, did not indicate malignant
degeneration. At any rate, it was very evident that an exploratory incision was neces-
sary. This was made on October 28, 1892. The ascitic fluid at once escaped from
the abdominal incision. A large fibro-cystic tumor of the ovary was found high up
on the left side, almost in contact with the diaphragm. The pedicle was at least eight
inches long. Owing to the great amount of solid matter in the tumor, it was necessary
to extend the incision upward nearly to the sternum. The tumor was then removed
with perfect ease and the pedicle tied and seared with the Paquelin. Cystic degenera-
tion had begun in the opposite ovary, which was as large as the first, so this was also
removed. The abdominal cavity was thoroughly washed with sterilized water and a
drainage-tube introduced. The convalescence was uninterrupted, and the patient
was discharged twenty-one days after the operation. The solid portion of the tumor
weighed nineteen pounds.
Operation.
CASE LXXXI.-Parovarian Cyst Weighing Twenty Pounds.
Recovery.-Patient æt. 33. Referred to me by Dr. A. Farnsworth of Saginaw, Mich-
igan. Unmarried. When 11 years old she was seriously ill from getting her feet wet.
Menstruation began at 15. Health good until six years ago, when she first noticed an
enlargement low down in the pelvic region. She suffered no pain with this, except
during the menstrual flow, which was profuse. Her appetite was good, she slept
well, and had attended to her duties as postmistress up to the time of entering the
hospital, October 23, 1890.
On October 24th the abdomen was opened in the usual way. The cyst was found
to be parovarian, the walls being very thin. It was partly intra-ligamentary, but was
enucleated without serious difficulty. The tube and ovary were bound down by
adhesions and were, therefore, removed. The folds of the capsule at its base were
stitched together by a running catgut ligature and the tissues cut away above it.
Owing to the free oozing from the surfaces of the capsule, the abdomen was washed
736
A TEXT-BOOK OF GYNECOLOGY.
with sterilized water and a drainage-tube introduced. Time of operation thirty
minutes.
The drainage-tube was removed on the third day, after which the temperature ran
up to 101°, and fluctuated between 100° and 102° for the succeeding six days.
During this time Arsenicum iodide 3 x was administered. She was discharged on
November 26th, and ultimately recovered her health perfectly.
CASE LXXXII.—Exploratory Incision for Papillomatous Degeneration of Ovaries.
Profuse Hemorrhage, which was Controlled by Extensive Gauze Packing.—Miss A.,
æt. 53, had suffered for years with symptoms of fibroid tumor, with profuse menorrhagia
and metrorrhagia, which nearly terminated her life upon several occasions. I examined
the patient some three years previously to the operation and found the pelvis packed
with a hard, solid tumor intimately connected with the uterus and presenting all the
characteristics of a fibroid. Two years previously to the operation the uterine hem-
orrhages ceased and the patient had seemingly passed through the menopause. The
enlargement within the pelvis remained quiescent for a year; then it suddenly
began to increase in size and at the time of the exploratory operation the pressure
symptoms were most distressing. It was utterly impossible to determine the charac-
ter of the tumor by physical exploration. The uncertainties of the case were pre-
sented to the patient and her friends and an exploratory incision was agreed upon.
I was assisted by Prof. D. A. MacLachlan and Dr. Mary Denison. After incis-
ing the peritoneum, a large quantity of ascitic fluid, tinged with blood, escaped. The
finger was cautiously introduced; but notwithstanding the great care observed, most
profuse and alarming hemorrhage set in. It was very evident that the patient would
quickly succumb unless this was controlled. The incision was, therefore, enlarged
above and below and the pelvis and lower abdomen were found completely filled with
papillomatous growths. To have attempted to remove these would have been homi-
cidal. Accordingly, I packed over and about the bleeding surfaces iodoform gauze—
introducing in all four yards—leaving the end projecting from the lower angle of the
wound. The abdominal incision above this was then quickly closed. The patient
was removed from the table in a state of collapse, but by the energetic use of stimu-
lants internally, per rectum, and hypodermatically, she rallied and lived for eight
weeks. A portion of the gauze was removed on the third day, the remainder being
left behind for four days longer. Of course, there was left a large cavity to fill in by
granulation. This cavity was for the first six weeks kept perfectly sweet by irriga-
tion through drainage tubes; but large portions of the papillomatous growths sloughed
away, and in spite of every effort the patient succumbed at the end of two months
from blood poisoning.
This case illustrates most emphatically the utility of gauze packing in controlling
hemorrhage. Without it I do not believe that the hemorrhage could have been con-
trolled, and the patient undoubtedly would have bled to death on the table.
CHAPTER XLVIII.
INFLAMMATORY DISEASES OF The uterine
APPENDAGES.
General Considerations.-In the chapter dealing with acute
inflammation of the uterus and periuterine tissue, I devoted a
short space to the consideration of acute salpingitis and ovaritis.
Acute inflammation of these organs was, however, considered
rather in the light of a complication of general pelvic inflamma-
tion than as a distinct pathological entity, and rightly so.
When the pelvic contents are implicated in the general inflamma-
tory attack the most deft diagnostician will be unable to deter-
mine, in at least the larger number of instances, the extent of
involvement of the ovaries and tubes.
In the chapter referred to, I mentioned certain symptoms
which, if present, would lead the student, in acute pelvic inflam-
mation, to suspect the involvement of the ovaries and tubes (v. p.
417). These are: excessive tenderness in the region of the
ovaries, pain, nausea, and vomiting. Additional evidence may be
obtained in reasonably favorable cases by palpating the enlarged
and tender ovary or ovaries, though I especially emphasized the
necessity of care during physical exploration while acute inflam-
mation of any of the pelvic organs exists. It remains for me,
then, in the present chapter, to discuss the acute forms of in-
flammation of the uterine annexa, not in detail, but to such an
extent as will enable the student intelligently to comprehend
those chronic forms of inflammation which are so frequently the
sequelæ of acute inflammation.
If the reader will refer to Fig. 173 he will obtain some idea of
the intimate lymphatic connection existing between the uterus
and its appendages. This illustration will enable him to under-
stand why it is that the tubes and ovaries are so often secondarily
involved in diseases of the uterus. The continuity of the mucous
47
737

738
A TEXT-BOOK OF GYNECOLOGY.
membrane lining the uterus and the Fallopian tubes, and the
close proximity of the ovaries to the fimbriated extremity of the
tubes, are additional reasons why salpingitis and ovaritis so often
follows in the train of metritis.
Varieties. I shall adopt the classification of Pozzi, because
it serves to indicate the various pathological changes which
FIG. 173.
LO
11
7
12
E BOULENAZ
C.DEVY
LYMPHATICS OF UTERUS.
1. Lymphatics coming from the body and fundus of uterus. 2. Ovary. 3. Vagina
4. Tube. 5. Lymphatics coming from the cervix. 6. Lymphatics to the iliac
glands. 7. Lymphatics to the lumbar glands. 8. Anastomoses uniting the ves-
sels of the cervix and of the body. 9. Small lymphatics in the round ligament
to the inguinal glands. 10, 11. Lymphatics of the tubes. 12. Ovarian ligament
(Poirer.)
the appendages, when they become diseased, may take on. This
classification is as follows:-
I. Non-cystic salpingitis,
II. Cystic salpingitis,
a. Acute catarrhal;
b. Acute purulent;
c. Chronic parenchymatous
(pachysalpingitis).
Hypertrophic, or vege-
tating variety;
Atrophic, or sclerous vari-
ety.
a. Hydrosalpinx, or serous;
b. Hematosalpinx, or hemorrhagic;
c. Pyosalpinx, or purulent.
INFLAMMATORY DISEASES OF UTERINE APPENDAGES. 739
NON-CYSTIC OÖPHORO-SALPINGITIS.
It will be observed that the term oöphoritis is excluded entirely
from the foregoing classification. Inasmuch as marked salping-
itis rarely, if ever, occurs without concomitant disease of the
ovary, it is well to note at once that the use of the term salping-
itis implies that both the tube and ovary are involved in the
inflammatory process; that, indeed, an oöphoro-salpingitis is
meant.
Etiology.-Acute metritis and endometritis are the chief
sources of the disease. It is maintained by Championnière
that the propagation occurs, in all instances, through the lym-
phatics. As proof of this, he cites the fact that, in at least the
majority of cases, the uterine extremity of the tube is not in-
volved, the external two-thirds being the part chiefly affected.
Pozzi teaches that the indemnity is apparent only, for the micro-
scope shows that the tissues of the inner third are markedly
inflamed. While it will not do to ignore the rôle played by the
lymphatics, especially during the puerperal state, it is probable
that the disease, in the greater number of cases, extends from
the uterus to the tubes by continuity of tissue. This is emphat-
ically so in specific endometritis.
The frequent association of metritis with salpingitis is often
overlooked when the symptoms of the former overshadow those
of salpingitis. An intense metritis may be associated with a
slight salpingitis without the latter condition being known; and,
conversely, if the disease is primarily located in the tubes or the
ovaries the metritis may pass unrecognized-hence the possi-
bility of failing to determine the simultaneous existence of the
two affections.
I have in another place * discussed gonorrhea as a causative
factor of endometritis and pelvic inflammations in general. Tait
maintains that the uterus and tubes may become infected by the
gonorrheal virus without the preëxistence of distinct vaginitis.
There can be no question that the significance of gonorrhea
as a causative factor, has not yet received the attention which its
*v. page 382.
740
A TEXT-BOOK OF GYNECOLOGY.
importance warrants, though it is possible that an exaggerated
significance has been given to it by Noeggerath. The fact that
the gonococcus of Neisser is not always found in the pus taken
from pus-tubes, by no means proves a non-gonorrheal source
of infection.
The next most frequent cause is puerperal infection. Mem-
branes retained after abortion become septic, thus giving rise to
metritis and succeeding salpingitis. Should, however, gonorrheal
infection precede abortion or parturition, the real cause of the
difficulty may be overlooked. The puerperal state, in instances
of this kind, tends to propagate the gonorrheal virus, and un-
doubtedly many cases of puerperal peritonitis and cellulitis are
due to gonorrheal metritis with secondary involvement of the
tubes, ovaries, and periuterine tissues. (Tait.)
The other causes are those which may give rise, if operative,
to metritis or general pelvic inflammation. They include the
improper use of the sound, operations upon the cervix, un-
skilful obstetric operations, and the want of proper surgical or
obstetric cleanliness.
Tubercular salpingitis is rarely met with as an idiopathic affec-
tion. It is usually associated, when it occurs, with tubercular in-
volvement of other abdominal and pelvic viscera. In those rare
instances where it is met with as an isolated lesion, its probable
origin is tuberculous spermatozoa which find their way into the
tube. This explanation will not, however, apply when the affec-
tion occurs in virgins. In such cases, according to Pozzi,
the tubercle bacillus is first introduced into the circulation
through the lungs or digestive tract, and finally lodges in the
tube.
The eruptive diseases-scarlatina, variola, etc.—are, according
to Tait, frequently responsible for disease of the tubes and
ovaries. This author, together with Freund, believes also that
congenital malformations of the tubes with atrophy predispose
to salpingitis.
Symptoms. In subacute and chronic salpingitis and ovaritis,
pain is an almost inseparable feature. It is, in at least nineteen
cases out of twenty, worse on the left side; and, if unilateral,
is almost certain to be located on the left side. (Tait.) It
INFLAMMATORY DISEASES OF UTERINE APPENDAGES.
741
is more or less persistent and is aggravated by walking or by
jars of any kind. It extends down the thighs into the back and
frequently involves, in a reflex way, the breast of the corres-
ponding side. It is almost always intensified immediately before
and during menstruation, giving rise to that form of dysmenor-
rhea known as "ovarian." Occasionally the pain is great enough
to prevent the patient from standing erect. Dyspareunia more
or less marked is rarely absent. This is due to the fact that the
inflamed ovary is nearly always prolapsed. A digital or bimanual
examination will, if the ovary is pressed upon, give rise to a
peculiar sickening sensation, which persists for some time after
the pressure is removed. In rare instances the suffering is
relieved by the onset of the menstrual flow.
Menstruation is oftener excessive than deficient in quantity.
This is due to the general pelvic congestion perpetuated by the
disease, as well as to the fundal endometritis which is rarely, if
ever, absent. When the ovaries become cirrhotic, partial or
complete amenorrhea may ensue.
The subjective symptoms alone are not sufficient for diag-
nostic purposes, and, especially if an abdominal section is con-
templated, a careful physical examination should be made under
ether. Even then it is not possible to detect micro-cystic de-
generation of the ovary or simple catarrhal salpingitis. In
chronic salpingitis, if the conditions are favorable, the tube can
be felt as a resisting, hard, tense cord.
Differentiation.-The following affections will call for differ-
entiation :-
Metritis ;
Lumbo-abdominal neuralgia;
Ovaralgia.
Metritis. It is unnecessary to repeat the special symptoms
belonging to this affection. Indeed, when the tube is inflamed,
traces of a preceding metritis usually exist. Should the symp-
toms of metritis still preponderate, it is utterly impossible to
determine with any degree of positiveness the extent of in-
volvement of the tubes and the ovaries. If the inflammation is
limited to the uterus the increased weight of the organ, together
•
742
A TEXT-BOOK OF GYNECOLOGY.
with its mobility, will at least suggest that the appendages are
not seriously implicated.
Lumbo-abdominal Neuralgia.—This is due, in the larger num-
ber of instances, to some affection of the uterus. The pain is
located in the abdominal wall and is made worse by superficial
pressure.
Ovaralgia.—Ovaralgia, or neuralgia of the ovaries, is not
infrequently associated with inflammation. Nevertheless it
often occurs as an idiopathic affection, if, indeed, it is right to
speak of any neuralgia as “ idiopathic." The pain is usually con-
fined to one side. It comes and goes in quick succession. The
attacks are oftener met with in hysterical patients and in women
who are victims of neuralgia in other parts of the body. There
may be anesthesia of the corresponding part of the body.
(Charcot.)
Since inflammation of the tubes is nearly always associated
with that of the ovaries, it is rarely possible to determine with any
degree of precision, even after a most careful local examination
has been made, which organ is chiefly affected. We are led to
suspect that the ovary is chiefly involved when the tumor is
oblong; when it is mobile and some distance from the uterus;
when the sensitiveness is very great; and when dysmenorrhea
is a marked symptom.
Prognosis.-Chronic salpingitis and ovaritis, whatever may
be the form of inflammation, is an exceedingly obstinate affec-
tion. Owing to the fact that all of the pelvic organs are periodi-
cally congested by the menstrual function, it is impossible to
bring to the diseased appendages physiological rest so long as
menstruation continues. The lining membrane of the tubes can-
not be gotten at for treatment as can the endometrium. There
is, too, a peculiar tendency for the tube to become occluded, both
at its uterine and its ovarian extremity, so that the secretions
are pent up. Nevertheless, relative cures may occur, even though
pus is present, though in nearly all cases the tube remains more
or less altered after an acute attack of salpingitis. Sterility is a
frequent sequela, though not an absolute one if the disease does
not involve the appendages of both sides. The symptoms are,
in nearly all instances, most persistent, and attacks of peritonitis
INFLAMMATORY DISEASES OF UTERINE APPENDAGES.
743
are of frequent occurrence. These attacks are supposed to be
due to a few drops of muco-pus escaping from the tube into the
peritoneal cavity, or to irritating fluid escaping from ruptured
ovarian follicles.
CYSTIC OÖPHORO-SALPINGITIS.
Of the three forms of cystic salpingitis pyosalpinx is the most
frequent. This, it is claimed, may be transformed into hydro-
and hemato-salpinx. The method by which this is brought
about is somewhat uncertain. It is probable that the germs are
spontaneously destroyed and the inflammatory process arrested,
when the pus undergoes a species of clarification and is con-
verted into serous fluid. This at least is the explanation of Pozzi,
who believes that the great majority of cases of hydrosalpinx
originate in this way. A hematosalpinx may result from the
rupture of the vessels in the walls of a pyosalpinx, the sac be-
coming filled with blood. A more frequent cause of hematosal-
pinx is Fallopian pregnancy, the ovum dying after rupture and
the tube remaining distended with blood. It may also be asso-
ciated with hematometra, due to obstruction within the cervix
or vagina.
Hydrosalpinx.-Tubal dropsy rarely attains a very large size.
It is not improbable that the large tubal cysts reported by the
older authorities were in reality distended tubes connected with
true ovarian cysts. They may, however, attain a size equal to
that of a fetal head. (Figs. 174 and 177.) The walls of the cyst
are thin and present a bluish white color.
Hematosalpinx.-The tumor produced by true hematosalpinx
is usually not larger than the fist. The contents consist of a
mixture of blood and pus, or of blood and serum.
It is neces-
sary to exclude from the category of hematosalpinx those slight
effusions of blood due to inflammation of the walls of the tube
which are susceptible of spontaneous reabsorption.
Pyosalpinx.-Purulent cysts of the tubes and ovaries vary in
size from that of a small pear to that of a fetal head. The sac
is also of variable thickness. The pus presents a creamy yellow
appearance and is often most offensive, especially if it communi-
cates with the bowel. Not infrequently the ovary contains dis-

744
A TEXT-BOOK OF GYNECOLOGY.
seminated abscesses; or it may be so intimately attached to the
fimbriated extremity of the tube as to become an integral part
of the cyst. (Figs. 175 and 176.)
Symptoms. Grouping the three forms of cystic enlarge-
ment of the tubes and ovaries under one head, is in entire har-
mony with clinical facts. That is to say, so far as both subjective
phenomena and local symptoms are concerned, it is usually im-
FIG. 174.
HYDROSALPINX.
A dilated left tube which weighed, inclusive of its fluid contents, 1 lb, 6 oz. From a
single woman, aged 23. The right Fallopian tube weighed, including its contents,
4 lb, II oz. (Museum R. C. S. Photographed by the Author.)
possible to differentiate the three affections from one another.
It is true that during the acute period of pyosalpinx the symp-
toms are more intense and the usual systemic disturbances attend-
ing the formation of pus in any part of the body may present
themselves. In due time, however, the pus within the tube usually
becomes latent and, if the encystment is complete, the system
will tolerate its presence without any constitutional disturbance.

INFLAMMATORY DISEASES OF UTERINE APPENDAGES. 745
Should the tube rupture, or the pus escape through the fimbri-
ated extremity into the peritoneal cavity, inflammation is more
apt to result than when the fluid from a hydrosalpinx escapes
into the pelvis. The frequent recurrence of chills and fever,
given by the older authors as conclusive evidence of pyosalpinx,
does not in fact take place even in the larger number of cases.
I have repeatedly found pus within the tubes when the most
FIG. 175.
TUBO-OVARIAN CYST.
A uterus with its appendages. Both Fallopian tubes are much dilated, especially the
right. This has formed a communication with the corresponding ovary, which is
dilated into a cyst over two inches in diameter. There are numerous adhesions
on the surface of the uterus, the result of chronic peritonitis. (Museum R. C. S.
Photographed by the Author.)
careful cross-questioning failed to elicit any of the supposed
classical signs of pyosalpinx.
Pozzi refers to another symptom of cystic oöphoro-salpingitis
the value of which, he maintains, has been much exaggerated,
namely, the sudden escape of sanguineous, purulent, or serous
fluid from the cervix, which may be frequently repeated. This
author believes that in at least the larger number of cases pre-

746
A TEXT-BOOK OF GYNECOLOGY.
senting such a history the fluid does not proceed from the
tube but rather from the uterine cavity, and that it is due to an
endometritis associated with more or less cervical stenosis. In
support of this view he cites the fact that cystic tubes are usually
obliterated at their uterine extremity. He nevertheless admits
that it is sometimes possible to force the contents of distended
tubes through the uterus and into the vagina by bimanual
pressure.
FIG. 176.
TUBO-OVARIAN CYST.
The uterine half of the tube is much elongated, thick-walled, and tortuous; it has
been laid open and lies posteriorly. The outer half of the tube is extremely
dilated. Masses of papillomatous growths spring from the mucous membrane
of the tube. The ovary, which is seen below, forms a large single cyst which
does not communicate with the interior of the dilated tube. (Museum R. C.
S. Photographed by the Author.)
The symptoms of hydrosalpinx are not usually so marked as
those of the other two varieties of cystic disease.
The amount of blood contained in a hematosalpinx is not
ordinarily great enough to produce serious constitutional dis-
turbance.

INFLAMMATORY DISEASES OF UTERINE APPENDAGES. 747
The general symptoms of the three forms of cystic disease are
those of pelvic peritonitis with which all are so often associated.
In all, pain will draw attention to the appendages. Upon physi-
cal examination a tumor will be found on one, or, if bilateral, on
both sides of the uterus. Care must be observed in practising
the bimanual not to rupture the cyst.*
FIG. 177.
T'
DOUBLE HYDROSALPINX. (Beigel.)
T, right tube with abdominal mouth closed; o, right ovary; T', left hydrosalpinx;
o', left ovary degenerated into a cyst.
If the appendages of both sides are involved, the uterus is always
more or less fixed. Usually the distended tubes will be found in
* In a case brought to me by Dr. W. I. Tyler of Niles, Mich., a local examination
revealed what seemed to be cystic distention of the right ovary and tube, the
tumor being as large as a small orange. In making the bimanual under ether, I was
not a little startled to have the cyst collapse between my fingers, evidently the result
of rupture. The patient was placed in bed, every precaution taken to guard against
peritonitis, and I held myself in readiness to make an abdominal section should the
symptoms indicate the escape of pus into the peritoneal cavity. The cyst evidently
contained innocent fluid, for no disturbance followed its rupture.
748
A TEXT-BOOK OF GYNECOLOGY.
the cul-de-sac, where they are adhered; or, they may be so embed-
ded in inflammatory|exudates as to be indistinguishable from the
general contents of the pelvis. Local examination always gives
rise to more or less pain. It is rarely if ever, possible to detect
fluctuation, unless a large distended tube is adhered in the cul-
de-sac and pushes the uterus forward. Not infrequently in pyo-
salpinx the adhesions to the contiguous parts are so intimate
that the tube loses its identity and cannot be enucleated. The
subperitoneal tissues may become involved in the suppurative
process, when the condition is converted into a true pelvic
abscess.
Differentiation.—It is, then, by no means possible to determine
at the bedside which of the three forms of tubal disease exists, nor,
from the standpoint of treatment, is the uncertainty of differentia-
tion very important. Whether the tube contains pus, blood, or
serum, if the distention is at all marked, operative interference is
called for. Lawson Tait goes so far as to say that a classification
of these cysts, based even upon the character of the fluid which
they contain, is thoroughly impracticable.
From the standpoint of prognosis, on the other hand, it is
important to determine the probable character of the fluid which
distends the cyst. All authorities agree that purulent pyosalpinx
is more dangerous than hemato- or hydrosalpinx. This is be-
cause of the intense peritonitis which usually results from the
escape of pus into the pelvic cavity.
A gonorrheal history, or a history of sepsis associated with
parturition or abortion, will lead us to suspect that the tube is
distended with pus. Unfortunately, it is by no means always
possible, as we have seen, to obtain a history of gonorrhea, even
though the source of infection be of this origin.
Other conditions suggesting pyosalpinx are: the presence of
extensive adhesions, frequent repetitions of pelvic inflammation,
and, possibly, the occurrence of erratic chills, such as suggest
pus in other parts of the body. It will not do, however, as I
have already intimated, to eliminate pyosalpinx because this last
symptom is wanting.
Both hydro- and pyosalpinx are nearly always bilateral,
whereas hematosalpinx is frequently confined to one side only.
INFLAMMATORY DISEASES OF UTERINE APPENDAGES.
749
This last fact suggests that Fallopian pregnancy is often respon-
sible for blood cysts.
Hydrosalpinx gives rise to adhesions much less often than do
the other forms of tubal distention. The bimanual is also less
painful when the cyst contains serum only.
Zweifel* makes the following observation regarding pyosal-
pinx: "In cases in which streptococcus and kapselcoccus were
found there was often every evening marked remittent fever. In
cases of tubercular pyosalpinx the fever rose from time to time;
wherein it differs from gonorrheal pyosalpinx in which there
was usually no fever at all when the patient was lying quietly in
bed. If disturbed by the examination, the temperature rose at
once and shortly after fell. In no case of gonorrheal pyosal-
pinx was there swelling of the inguinal glands, while in pyogenic
cases swelling was the rule."
Cystic oöphoro-salpingitis may be confounded with-
Uterine fibroids;
Fibro-cystic tumors of the uterus ;
Small ovarian cysts;
Early tubal pregnancy ;
Intraligamentous cysts.
Uterine Fibroids.-There is an entire absence of fluctuation;
the uterus is mobile; the depth of the cavity is increased; and
the tumor is intimately blended with the uterus, except in
pedunculated subserous fibroids.
Fibro-cystic Tumors of the Uterus.-The difficulties of differ-
entiation are sometimes very great. The size of the uterus
is usually increased; the pain is not so marked; and in most
cases the inflammatory history is wanting.
Small Ovarian Cysts.-The tumor is more remote from the
uterus; there is an absence of tenderness; and no history of
pelvic inflammation can be obtained.
Early Tubal Pregnancy.-The uncertainty previously to the
period of rupture is very great. The increase in the size of the
uterus is usually more marked than is the case with tubal
disease. The ordinary symptoms of pregnancy-suppression
* Annual of Universal Medical Sciences, 1892.
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A TEXT-BOOK OF GYNECOLOGY.
of the menses, changes in the breasts, etc.—may exist. The ir-
regular spasmodic pain associated with tubal pregnancy is very
much like the pain incident to cystic tubal disease.
Intraligamentous Cysts.-These dissect the folds of the broad
ligament so that they are in intimate contact with the uterus.
There is an absence of inflammatory symptoms.
Two most curious and interesting cases are cited by Doleris*
of adherent enterocele in the cul-de-sac of Douglas, in which
the conditions simulated very closely an inflammatory tumor of
the appendages. The diagnosis was made only after the abdo-
men was opened.
THE PATHOLOGY OF NON-CYSTIC AND CYSTIC DISEASES OF
THE UTERINE APPENDAGES.
In simple catarrhal salpingitis (acute and subacute) the secre-
tion is increased and there is more or less swelling and redness
of the mucous membrane. There may also be shedding of the
epithelium, wholly or in part, with thickening of the villi. The
infiltration of the tube wall is usually very slight, though the
swelling is sometimes great enough to be detected upon bimanual
examination.
In purulent salpingitis (acute and subacute) there is often found
a pus-forming organism such as the streptococcus or kapsel-
coccus. This may result either from sepsis following abortion,
or labor at term, or from gonorrhea. The folds of mucous
membrane are often increased, and frequently there are formed
small pus cavities, or cysts of like character. (Chrobak.)
In pachysalpingitis (chronic parenchymatous) there is excessive
development of the tube wall due to increase of the connective
tissue rather than to hypertrophy of the muscular. The mucous
membrane is usually involved to a greater or less extent, its
folds being hypertrophied. Vegetations not infrequently spring
from the surface of the mucous membrane.
In cystic distention of the tube, which is frequently preceded
by one of the non-cystic forms of salpingitis, there is agglutina-
tion of both the uterine and the fimbriated extremity of the tube.
* Pozzi, "A System of Gynecology," p. 389.
INFLAMMATORY DISEASES OF UTERINE APPENDAGES. 751
The dilatation is oftener located at its external two-thirds, though
it may involve its whole length. The pavilion attaches itself
very often to the ovary, which may become fused with the cyst.
Adhesions may attach the appendages to any part or organ of
the pelvis, but oftener to the Douglas cul-de-sac. A suppurat-
ing cyst of the broad ligament or ovary may communicate with
the tube. Microscopically, ramifying vegetations are found pro-
jecting from the lining membrane of the tube. Its walls are
infiltrated with embryonic cells. All of the vessels are markedly
dilated.
If the ovary is the seat of chronic inflammation, it may
localize itself largely, either in the follicles of the gland or in its
fibrous tissue. In the first instance there is an increase in the
number of follicles, resulting, according to Tait, from hyperemia.
Instead of a general involvement of the follicles the follicular
hypertrophy may confine itself to a few only, which condition
constitutes a variety of cystic degeneration. (Rokitansky.) This
form of cystic degeneration frequently gives rise to great suffer-
ing and most profuse menorrhagia.
Fibrous hyperplasia may be the most characteristic feature of
ovarian inflammation. Here there is destruction of the follicles
and an arrest of the development of the proper ovarian cells.
Secondary contraction follows the hyperplasia and gives rise to
so-called cirrhotic degeneration. This is nearly always attended
with dysmenorrhea of a most serious character. In time it gives
rise to amenorrhea more or less absolute.
*
In still another condition there may be great enlargement of
the ovary due to hypertrophy of both the follicular and the
fibrous elements of the gland, the relative proportions of the two
structures remaining normal. Tait observes that the tubes are
nearly always hypertrophied with the ovary. He says: "I
have removed ovaries for intractable pain and hemorrhage which
weighed as much as ten hundred and twelve grains, yet the most
careful and minute examination of the organ revealed nothing
more than an absolutely normal structure."
The ovary may be destroyed by the processes of suppuration.
* Op. cit. p. 430.
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A TEXT-BOOK OF GYNECOLOGY.
An abscess of the ovary unassociated with disease of the tube is,
however, an exceedingly rare condition. The pus may be dis-
seminated throughout the ovary, or one large abscess may
occupy the center of the organ. In one of my cases the ovary
was a mere shell and contained three ounces of pus.
Progress and Termination: Prognosis.-In the various
forms of non-cystic inflammation of the tube a relative cure is en-
tirely possible. Undoubtedly too many tubes and ovaries have
been sacrificed by enthusiastic laparotomists. Whether or not
an absolute cure can be brought about after the tubes undergo
interstitial changes, even by the most careful and skilful treat-
ment, is very doubtful. It is, however, usually possible to make
the patient very comfortable, even though such changes are the
result of gonorrheal inflammation. Unfortunately cases are every
now and then met with where, although no cystic distention exists,
the dysmenorrhea and menorrhagia, as well as the general suf-
fering, are such as to make salpingoo-öphorectomy the only
resource. This should not be resorted to until all ordinary
measures have been exhausted. Life is not endangered as it is
in pyosalpinx, for in the latter affection rupture is liable at any
time to occur and cause fatal peritonitis. I think it can be safely
said that with the means now at our command, ablation of the
appendages is unnecessary in at least ninety per cent. of all cases
of non-cystic salpingo-oöphoritis.
The duration of the affection is often prolonged and the physi-
cian has to contend with the periodical congestion incident to
menstruation. Nevertheless, a healthy conservatism has sprung
up during the last few years and the specialists are resorting to
salpingo-oophorectomy much less frequently than in the past.
The curability of cystic accumulations is quite another matter.
A woman is not for a moment safe while carrying within her
pelvis a distended tube. In the first place, it is utterly impossible,
as we have seen, to determine the exact character of the fluid
within the cyst previously to its removal. Attacks of inflamma-
tion are of frequent occurrence, and should rupture take place
serious and even fatal peritonitis may be excited. In fact, these
accumulations are rarely if ever cured spontaneously, though
occasionally adhesions form between the rectum and the vagina,
INFLAMMATORY DISEASES OF UTERINE APPENDAGES. 753
through which their contents may escape. Unfortunately, an
abscess opening into either of these cavities, especially into the
rectum, usually continues to discharge indefinitely, giving rise
to tenesmus, shooting pains, diarrhea, etc. I have recently had
under observation a case of this kind, coming to me from the
hands of an ultra "conservative" physician, where intermittent
discharges of pus from the bowels took place every three or four
months for five or six years, the patient finally succumbing to
the disease. Occasionally the contents escape externally.
The suffering in the cystic distention is frequently very great,
and this in itself calls for radical measures. The pain is due to
plastic adhesions and to distortion of the pelvic viscera which
result from the frequent attacks of inflammation. The menstrual
symptoms, particularly dysmenorrhea and menorrhagia, are
usually marked. When the ovarian stroma is entirely destroyed
menstruation may cease entirely.
48
CHAPTER XLIX.
INFLAMMATORY DISEASES OF THE UTERINE
APPENDAGES-(Continued).
TREATMENT OF NON-CYSTIC AND CYSTIC OÕPHORO-SALPINGITIS.
The conservative treatment of inflammation of the Fallopian
tubes and ovaries is applicable to the non-cystic forms only. In
that large class of affections so frequently met with, where en-
dometritis or metritis has extended beyond the uterus and has
implicated the appendages, conservatism is eminently proper, for
much relief may be afforded and a relative cure accomplished in
a goodly per cent. of cases. The principles of treatment applic-
able to these affections do not differ essentially from the treat-
ment of general pelvic inflammation. Rest, especially during
and just before the menstrual periods, is of the first importance.
The hot douche administered in such a way as to bring into
action its thermic properties is invaluable; it may be advan-
tageously supplemented by the hot bath, or by sea-bathing.
Uterine drainage should be secured and the proper medicaments
applied to the endometrium. Electricity is, I am convinced, an
agent of inestimable value in contending with non-cystic tubal
disease. My method of applying it is to localize the galvanic
current within the pelvis by passing a suitable electrode into the
uterus and a large dispersing pad over the abdomen. In this
way a current of from twenty to forty milliampères should be
used for from five to ten minutes at each séance, and repeated
twice or three times a week. Medicated tampons of cotton
wool should be inserted after any form of local treatment.
Finally, a carefully selected remedy should be administered.
I desire to emphasize the necessity of patience and persis-
tence in carrying out the line of treatment indicated in the
foregoing. There are so many factors to contend against, that
the physician will be disappointed if he expects to accomplish
a cure in a few weeks' time. Of this fact the patient should
754
INFLAMMATORY DISEASES OF UTERINE APPENDAGES.
755
be apprised. With a possible abdominal section confronting
her, she is usually most willing to coöperate with her physician
in carrying out any kind of conservative treatment. Unless the
suffering is very great, and the symptoms most urgent, I do not
believe that we are justified in resorting to laparotomy in non-
cystic tubal affections without at least a six months' trial of con-
servative treatment.
In dealing with the cystic diseases, on the other hand, blind
conservatism is most reprehensible. A woman who has a dis-
tended Fallopian tube, and who suffers from frequent attacks of
peritonitis, can have no greater misfortune come to her than to
fall into the hands of a physician incapable of comprehending
the dangers which beset his patient. The medical attendant
advises against an operation and the case progresses from bad
to worse until finally a point is reached where an operation, if
done at all, must be done when she is practically moribund.
Salpingo-oophorectomy, under favorable circumstances, is not
a dangerous operation. If, however, the patient is suffering from
acute peritonitis, the result of rupture, if her strength has been
depreciated by long continued suffering, if, in short, the operation
is done as a last resort," the circumstances are very different.
The abdominal surgeon who does his full duty will save a
certain per cent. of these neglected cases, but his mortality
record will suffer accordingly.
Salpingo-oophorectomy for Inflammation of the Append-
ages.-Salpingo-oophorectomy, when performed for the inflam-
matory diseases of the tubes and ovaries, may be a very easy or
a very difficult operation. It is usually more difficult than is an
ordinary ovariotomy. The reasons for this are, that the abdom-
inal walls are not stretched by the presence of a large tumor,
and associated with the disease of the appendages there are
usually extensive adhesions which distort all of the pelvic
organs.
The preparatory treatment does not differ from that recom-
mended in Chapter XII. The waterproof sheet is unneces-
sary. The incision is made in the middle line, extending from
about two and a half inches above the pubes to three inches
below the umbilicus; an incision of from two to three inches in
756
A TEXT-BOOK OF GYNECOLOGY.
length will ordinarily afford sufficient room. Upon opening the
peritoneum the omentum and intestines are, if not adherent,
pushed forward, and the surgeon passes the two fingers of his
right or left hand downward toward the fundus uteri. The fun-
dus will serve as a guide for future operations. The extent of
the adhesions is most variable. The omentum is not infrequently
attached to the bladder, intestines, or uterus; when this is the
case, these adhesions should be first detached. The omentum
may
also attach itself to the tube and ovary, which are sometimes
lifted from the pelvis by it. In dealing with omental adhesions
which cannot be separated in the ordinary way, it is best to cut
them between two pairs of catch-forceps; later, a ligature can be
applied to their proximal end. The surgeon next explores the
appendages by passing the fingers of his right hand over the
fundus of the uterus along the broad ligament and Fallopian
tube on either side. Not infrequently the distortion is so
great as to make it exceedingly difficult to distinguish the
various pelvic structures and organs from one another. Usu-
ally, however, the fundus of the uterus will afford a land-
mark by which the surgeon can locate the tubes. It may
be that the ovary and tube, though diseased, are easily drawn up
through the abdominal wound. If so, they are secured in a
Staffordshire knot and cut away. It is best to leave the ligature
long until the opposite appendages are secured. In other in-
stances, perhaps the majority, the tube and ovary are firmly fixed
deep in the pelvic cavity, the most frequent site of the adhesions.
being the cul-de-sac of Douglas. A great deal of force may be
required to free appendages thus adhered.
If the operation is once undertaken, there are very few instances
where it ought to be abandoned. A possible exception to this
rule occurs in those cases where the adhesions are universal, and
where the patient's condition will not warrant extensive intra-
abdominal manipulations. If it is possible, in these cases, to
open the tube and drain it through the abdominal wound, it may
be wise to proceed in this way. However, Lawson Tait has
taught the profession that, unless the circumstances just enum-
erated exist, incomplete salpingo-oophorectomy ought rarely, if
ever, to occur. I have seen this operator remove the appendages
INFLAMMATORY DISEASES OF UTERINE APPENDAGES.
757
when it was absolutely necessary for him to tear by sheer force
the large sacs from the pelvic cavity. I have taken much
greater chances in desperate cases since seeing him operate.
In dealing with adhesions deep in the pelvis it is best to de-
pend entirely upon the sense of touch. After determining the
actual limits of the diseased organs, they are gradually unfolded
from below until a pedicle is formed. Even after they are un-
folded in this way, the tube and ovary cannot always be brought
out of the abdominal wound, for the changes within the broad
ligament may leave them so unyielding as to make this impos-
sible. It is here necessary to enlarge the abdominal wound and
secure the ovary and tube within the abdomen in one or more
ligatures. Tait, in these cases, carries his finger down to the pelvic
insertion of the broad ligament and causes a series of minute tears
at this point through the peritoneum and fibrous fascia. This
leaves the ligament elastic and distensible without endangering
the vessels running through it.
The hemorrhage following the separation of extensive adhe-
sions is sometimes very great and it should be temporarily con-
trolled by sponge packing.. After the appendages are removed,
if the hemorrhage still persists, a solution of iodin may be
applied to the bleeding surfaces, or the parts may be seared over
with the Pacquelin cautery. Any spurting arteries are, of course,
secured by forcipressure, or by ligatures. It may even be ne-
cessary to leave several pairs of forceps attached to the bleeding
points for some hours after the operation. Usually, however, if
the hemorrhage is simple oozing, it can be controlled by sponge
packing.
In dealing with distended tubes, especially if the contents are
purulent, care should be taken not to permit the pus to escape
into the peritoneal cavity. If there is danger of rupture it is
best to evacuate the tube with an aspirator and close the open-
ing thus made by pressure forceps. If pus escapes into the peri-
toneal cavity, or if the oozing is very profuse, irrigation with hot
sterilized water should always be resorted to. It is my practice
in these cases to leave the abdomen distended with water. When
extensive adhesions have been separated, and especially if the
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A TEXT-BOOK OF GYNECOLOGY.
peritoneum has been contaminated by pus, a drainage tube is
imperative.
It is nearly always necessary to remove the appendages of
both sides although the disease may be very much more exten-
sive on one side than on the other. Tait especially emphasizes
the importance of this practice. Even though the disease of the
opposite side is not extensive it is very liable to become so after
the first operation. If, however, the patient is especially anxious
to have the appendages of one side conserved, her wish should
receive due consideration, though the probabilities of a second
operation should be presented to her.
The after treatment of salpingo-oophorectomy does not differ
from the after treatment of laparotomies in general.
Illustrative Cases.
CASE LXXXIII.—Pyosalpinx, the Result of Gonorrheal Infection. Oöphoro-sal-
pingotomy, followed by Intestinal Obstruction. Reopening of the Abdomen at the end
of Forty-eight Hours. Recovery.—Patient, American, æt. 24. Referred to me by my
former assistant Dr. C. M. Thurston of New Castle, Indiana. Married for five years.
Entered the hospital November 7, 1892. Menses came on at the age of twelve and she
has not been well since. The menses have always been irregular, too profuse and very
painful. The pain during menstruation is located in the uterus and ovaries; indeed, there
is constant soreness and suffering in both of these regions. There is a history of gon-
orrheal infection four years ago, since which time she has been very much worse in
every respect. Following this attack she was for a long time very low with pelvic in-
flammation. Attacks of pelvic peritonitis since then have been very frequent. She
has been compelled to leave her husband because of excessive venery. Menstruation
is now very profuse and each period leaves her greatly exhausted. There is more or
less increase of temperature during the periods. Appetite good; bowels constipated.
The urine is either scanty and high colored, or light colored and profuse. It contains
small quantities of albumin, pavement epithelium, a few crystals of oxalate of lime,
red blood cells and pus. The albumin is no more than can be accounted for by the
presence of pus.
A physical examination shows very great tenderness of all of the pelvic organs, with
retroversion of the uterus and fixation. An ill-defined mass is distinguished at the
left of the uterus but gives rise to no evidences of fluctuation.
Because of the excessive pain, the dyspareunia, and the intractable uterine hemor-
rhage, laparotomy was recommended. The abdomen was accordingly opened on
November 24th, 1892. The adhesions of the omentum to the uterus and left tube were
very firm and had to be cut. The pelvis was filled with inflammatory exudates, the
result of the frequent attacks of peritonitis. It was, however, possible to distinguish
the fundus of the uterus by carrying the finger along the left broad ligament. The
corresponding tube was found distended with pus and firmly fixed in the cul-de-sac of
Douglas. The ovary was implicated in the suppurative process, constituting a true
INFLAMMATORY DISEASES OF UTERINE APPENDAGES.
759
tubo-ovarian cyst. It required a great deal of force to peel the cyst from the posterior
layer of the broad ligament and from the cul-de-sac. However, I finally succeeded in
doing this by first securing the tube at its uterine extremity and afterward tying in sec-
tions the broad ligament at the pelvic extremity of the tube. The tumor was filled with
inspissated pus in which no gonococci were found. The left tube and ovary, though
not greatly enlarged, were firmly adherent and were removed. The right ovary showed
well-marked hyaline and cystic degenerative changes.
There was left behind, after removing the cyst, a large bleeding surface which con-
tinued to ooze in spite of sponge pressure and the application of iodin. I therefore
packed this surface with iodoform gauze, leaving one end projecting from the lower
extremity of the wound. This was the only form of drainage used.
The patient rallied from the operation, but twenty-four hours later began to develop
symptoms of intestinal obstruction. These became more marked until the end of
the second day, when it was clearly evident that the only way to save her life would
be to re-open the abdomen. This was done forty-eight hours after the first operation.
A knuckle of intestine was found attached to the site of the adhesions, which was
the cause of the obstruction. The intestines were enormously distended with gas,
and immediately upon re-opening the wound forced themselves from it. They were
punctured in numerous places with a fine hypodermic needle in order to permit the
gas to escape; the abdomen was then washed with sterilized water, a glass drainage
tube inserted, and the abdominal wound reclosed. It was with great difficulty that
the intestines were returned to the abdominal cavity.
The vomiting soon ceased, the temperature dropped to normal, flatus began to pass
per anum, and from this time on the patient made an uninterrupted recovery. She
reports herself, one year later, in perfect health.
I am sure that, had the second operation not been done, she would have died from
the intestinal obstruction.
CASE LXXXIV.-Pyosalpinx of Right Side with Cystic Degeneration of the Ovaries.
Retroflexion of the Uterus. Salpingo-oophorectomy and Hysterorrhaphy. Recovery.—
Patient, æt. 28; referred to me by Dr. G. D. Green of Mason, Michigan. Married,
and has had two children, both being dead. She entered the hospital December 1,
1891, and gave the following history: Mother suffered more or less from lung trouble.
Father died of phthisis two years ago. Has one brother with weak lungs. When
young she was the picture of health. Began to menstruate at sixteen; the function
has always been irregular, occurring every two or three weeks. Menses too profuse,
the discharge being dark and often clotted. There has always been, too, a dysmenor-
rhea of a most marked character. The pain is in the uterine region, appearing before,
and continuing during, the flow. It extends to the back and is of a most excru-
ciating character. Has a profuse, excoriating leucorrhea between the menses, which
compels her to wear a napkin during the entire interval.
Her first child was born six years ago, labor lasting about ten hours. Was in bed
for fourteen or fifteen days, and did not get up well. The second birth was prema-
ture, occurring two years ago. Soon after the last confinement she had a severe attack
of peritonitis, the result of a fall, since which time there has been almost constant pain
in the right side, extending down the inner side of the corresponding limb to the
middle of the thigh. This pain is very intense and deep-seated. She is now compelled
to keep her bed during the entire menstrual period. The menstrual pains are labor-
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like in character, gradually growing worse as the period advances, and continuing for
some days after the flow ceases. Headache is almost constant, and is worse after
menstruation; it is located at the base of the brain and forehead. Appetite is poor
particularly during menstruation.
A bimanual under ether showed the fundus of the uterus retro-displaced, but it
could be lifted out of the hollow of the sacrum. The products of inflammation were
clearly outlined in the right broad ligament. The tube of that side was enlarged and
evidently distended. Both ovaries were enlarged to at least three times their normal
size.
The abdomen was opened on December 12, 1891. The right ovary and tube were
firmly adhered and were removed with some difficulty. The left tube was not en-
larged, but the ovary was clearly diseased and the appendages of that side were
accordingly removed. The fundus was stitched to the anterior abdominal wall by
means of two silk sutures. The intervening peritoneum was irritated with the
point of a scalpel for the purpose of exciting adhesions. The abdomen was closed in
the usual way without drainage. An examination of the appendages after their
removal showed the right tube distended with pus; both ovaries had undergone cystic
degeneration.
The patient convalesced with hardly a bad symptom. The abdominal sutures were
removed on the seventh day, those passed through the uterus being left behind for
three days longer. She returned home four weeks from the time of the operation
and is now (eighteen months later), except for the flushes of heat which still distress
her more or less, perfectly well.
Case LXXXV.-Hydrosalpinx of Right Side with Cystic Degeneration of Corre-
sponding Ovary. Interstitial Salpingitis of Left Side with Cirrhotic Degeneration
of Left Ovary. Salpingo-oöphorectomy. Recovery.-Patient, æt. 34; referred to
me by Dr. E. A. Lodge of Milford, Michigan. She entered the hospital October 10,
1891, and gave the following history: Was very healthy until menses occurred. at
fourteen, since which time she has never been well. Suffered from intense neuralgia
of the head from fourteen to twenty. Menses always lasted from five to seven
days, recurring about every twenty-four days.
Was married at twenty-four, and has never been pregnant. The uterus has been
displaced to the right and backward for several years. During menstruation she
suffers from a most excruciating pain in the ovarian region which completely pros-
trates her. There is much tenderness over the lower abdomen at this time with a
slight increase of temperature.
There is, in addition to the foregoing, a flatulent dyspepsia which is always aggra-
vated at the menstrual period. She suffers a great deal from pain which begins in
the back of the neck and extends up to the temples through the head.
last year there has been almost constant pain in the small of the back.
is not marked.
During the
Leucorrhea
The bimanual revealed an unusually large vagina for a woman who had never had
children. There was an ill-defined thickening on the right side, and on the left there
was evidently a distention of the tube. Physical examination caused much pain.
The abdomen was opened October 13, 1891. The uterus was found drawn to the
right by the inflammatory exudates of that side. The left tube was distended with
serum, and the right was greatly thickened as a result of interstitial salpingitis. The
INFLAMMATORY DISEASES OF UTERINE APPENDAGES.
761
right ovary was enlarged and cystically degenerated. The left had undergone atrophy
and was not larger than a Lima-bean. Both appendages were removed without
serious difficulty and the abdomen closed in the usual way.
The convalescence was interrupted on the seventh day by the patient eating freely
of honey which was surreptitiously conveyed to her. This gave rise to severe enteritis
with peritonitis, which nearly terminated fatally. She recovered from this attack,
however, and was permitted to sit up on November 1st. On November 3d she
walked across the room, and a week later left the hospital for her home. She is now
quite well.
CASE LXXXVI.-Oöphoritis of Twenty Years' Standing. Complete Prostration
from Neurasthenia. Salpingo-oophorectomy. Recovery.—Patient æt. 32; unmarried;
referred to me by Dr. A. B. Spinney of Detroit, Michigan. Her mother died of
gastric fever. Father is well, aged 68. One brother living; strong and well. One
sister living, not in good health. When she was about fourteen years old she fell and
struck the small of her back. When sixteen had sharp neuralgic pain in the left
ovarian region, made worse by being on her feet. Was compelled to leave school at
seventeen. Began to menstruate at fourteen; has always suffered greatly from dysmen-
orrhea, the flow being too long and too profuse. The pain comes on a day or two
before the flow and continues during it.
Her mother died ten years ago, after a six weeks' illness, during which the patient
had practically the entire care of her, especially at night. After her mother's death
she was bedridden for two years, during which time the ovarian pain was greatly ag-
gravated. She placed herself under the care of a physician who resorted to local
treatment, which consisted largely of applications of nitrate of silver to the cervix. At
the end of two years she was able to get up and about, though the pain in the ovarian
region was still more or less persistent. Two years ago she fell on the ice, again in-
juring her back. To use her own expression, "the backbone felt as though it were
driven through the head." A week later the ovarian distress became intensified and
there was swelling and tenderness of the corresponding side. The temperature was
increased and nausea and vomiting were marked symptoms. She was confined to
her bed for five months. Spinal irritation has been a marked symptom for the last
two years, during which time she has been bedridden. A physical examination
showed enlargement of the right ovary with very great tenderness. There is endome-
tritis with a small mucous polypus projecting from the cervical canal. Neurasthenia
is most profound.
Local galvanism was applied to the ovary and to the spine. The only additional
local treatment consisted of hot douches administered twice a day. Cimicifuga and
bryonia were given internally and every means taken to improve the patient's nutrition.
She, however, made but little progress under this treatment and an abdominal section
was decided upon.
The abdomen was opened on December 4, 1888. The right ovary was at least
four times its normal size and the tube greatly thickened. The fimbriated extremity
of the tube was adhered to the ovary. The left tube and ovary were likewise impli-
cated in the inflammatory process, though to a less extent. It was, however, deemed
best to remove the appendages of both sides. The abdomen was closed in the usual
way.
A slight attack of peritonitis followed the operation, the temperature rising on the
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A TEXT-BOOK OF GYNECOLOGY.
following day to 102°. This subsided and the sutures were removed on the seventh
day. She regained her health somewhat slowly, but was able to leave the hospital on
February 9th.
Three years later, while coming from Detroit to Ann Arbor, I was approached by a
lady who introduced herself as this patient. The change was so great that I did not
recognize her. She had taken on flesh and was, indeed, the picture of health. She
steadily gained after returning home, is now supporting herself by teaching school,
and is in every way perfectly well.
I have selected from my series of cases of inflammation of the
appendages the foregoing, as typically illustrating the benefit to
be derived from salpingo-oophorectomy when the operation
is indicated. In the chapter devoted to hystero-neuroses I
have referred to several additional cases in which salpingo-oöpho-
rectomy was done for various nervous troubles. It is not neces-
sary at this time to introduce further evidence illustrating the
utility of the operation under proper circumstances. I will sim-
ply add that, especially if done for nervous lesions, discrimina-
tion should be made with the utmost care. In all of my cases,
except when life was immediately threatened, both internal and
local measures were exhausted, either by myself or by the medi-
cal gentlemen who referred the patients to me, before laparotomy
was resorted to.
CHAPTER XLIX.
DISEASES OF THE UTERINE APPENDAGES
(Continued).
CONGESTION OF THE OVARY.
Pain in one or in both ovarian regions is frequently met
with, especially just before and during menstruation. This pain
may be stinging or burning in character; or the patient will de-
scribe it as a dull, cutting or sickening sensation. It is oftener
met with on the left side, and radiates down the inner part of the
thigh, or to the small of the back. It is usually worse some days
previously to and during menstruation, and gives rise to that type
of dysmenorrhea known as “ ovarian." Menorrhagia is likewise
a frequent symptom, though in time the menses may become scant
rather than excessive. The condition is often associated with
neurasthenia and nervous manifestations of various kinds. There
is tenderness upon pressure over the side affected. Other symp-
toms are headache limited to the vertex, pain under the breasts
of the corresponding side, constipation, flatulency and nausea
and vomiting. In the worst cases there may be hysterical out-
breaks and even hystero-epilepsy.
The lesion of the ovary giving rise to this group of symptoms
is described by many authors as chronic ovaritis, and, probably,
the congestion many times results in inflammation. However, the
symptoms characteristic of true inflammation are often wanting.
There is, to be sure, more or less enlargement of the organ, but
the subjective symptoms come and go, and, if the ovary is
removed, the evidences of actual inflammation are wanting.
Undoubtedly, pain of the character described is often due to
simple congestion. When the ovary becomes surcharged with
blood, its unyielding fibrous investing membrane prevents its
expansion, and there is pain not unlike that resulting from orchi-
tis. It is brought on and is made worse by any cause giving
rise to pelvic congestion. Immoderate coitus, the various
763
764
A TEXT-BOOK OF GYNECOLOGY.
methods resorted to for preventing conception, constipation,
ungratified sexual desire, irritation of the uterus or of the cer-
vix-any or all of these causes may result in simple conges-
tion of the ovary, which stops short of actual inflammation.
In the treatment of ovarian congestion it is necessary, first
of all, to remove the cause or causes which tend to per-
petuate the mischief. Rest is important. Long - continued
standing or walking should be avoided; running the sewing-
machine is responsible for many cases of ovarian congestion and
inflammation. It is better for the patient while undergoing
treatment to live absque marito, though nothing more fortunate
could befall her than pregnancy, for utero-gestation followed by
lactation, is the nearest approach to physiological rest which
can be given the ovary. Unfortunately, most women thus
affected are sterile. Constipation should be overcome and the
hot douche administered once or twice a day. Two or three
times a week a galvanic current of from fifteen to twenty milli-
ampères should be passed through the parts, with the positive
pole within the vagina. This should be followed by the intro-
duction of a boro-glycerid tampon medicated with the fluid ex-
tract of belladonna. Internally, belladonna, apis, cimicifuga,
lilium tig., lachesis, collinsonia, and bryonia are the remedies
oftener indicated.
PROLAPSE OF THE OVARY.
Non-adherent prolapse of the ovary is due, in nearly all in-
stances, to chronic ovarian congestion or inflammation. One
or both ovaries may be prolapsed, though the left, for obvious
reasons, is the one oftener displaced. The symptoms of this
accident are sufficiently urgent to call for special consideration.
Symptoms.-Ovarian prolapse is often associated with retro-
displacement of the uterus. There are few complications which
it is more difficult to contend against without resorting to radical
measures, than a retroflexed fundus under which is a prolapsed
ovary. The condition gives rise to pain upon walking which is of a
sickening, throbbing character, and is especially aggravated by
stool. It is located in the inguinal or sacral region and extends
down the thighs. The paroxysm is frequently precipitated by
PROLAPSE OF THE OVARY.
765
some unusual effort, as jumping from a carriage. Dyspareunia
of a most distressing character is likewise caused by the dis-
placement. The mental and nervous symptoms do not differ
from those described under the head of chronic congestion of
the ovary.
Diagnosis. The peculiar sickening character of the pain,
aggravated as it is by walking, stool, and sexual intercourse,
will suggest the cause of the difficulty. Upon making a digital
examination a small almond-shaped tumor will be found in the
posterior fornix which, when pressed upon, is exquisitely
tender, and gives rise to a sinking sensation in the epigastric
region, and sometimes to actual vomiting. If not adhered, it
can be pushed out of the cul-de-sac. The excessive tenderness
will serve to differentiate the displaced ovary from a small
pedunculated fibroid. It can be distinguished from a retroflexed
uterus by passing the sound.
Treatment. The various measures having for their object
the relief of pelvic congestion should be applied. If the uterus
is retro-displaced, this should be reposited and a suitable pessary
fitted. Unfortunately, the position of the ovary will not often
permit the use of a Hodge pessary. Sometimes an air pessary
(Fig. 119) will be tolerated when no other form can be worn.
The knee-chest posture frequently resorted to is of much value,
as are also the hot douche and properly applied tampons. A soft
lambs-wool tampon placed in the posterior fornix while in the
knee-chest posture, is often the only form of support which the
patient can endure. (v. p. 150.)
The general measures recommended for ovarian congestion
may be tried. Unfortunately, after the organ has been pro-
lapsed for some time, it is exceedingly difficult to effect a cure
without permanently fixing the uterus in front. The condition
gives rise to so much distress and suffering that, after all ordi-
nary measures have been exhausted, the physician is justified
in performing laparotomy, removing the offending organ, and,
if the uterus is retro-displaced, attaching it to the anterior ab-
dominal wall.
766
A TEXT-BOOK OF GYNECOLOGY.
OVARIAN NEURALGIA (OVARALGIA).
Ovarian neuralgia, or ovaralgia, may be due to a number of
causes. Of these the so-called neuralgic diathesis is first to be
mentioned. This means, in most instances, some depravity of
the system, the result either of improper food, excessive tea-
drinking, or undue exposure. Ludlam is of the opinion that
daughters of rheumatic fathers inherit a special tendency to
ovaralgia. Undue sexual excitement, disease of the uterus, and
traumatism are other causes worthy of consideration.
Symptoms. The patient is suddenly seized with an acute
paroxysm of pain of a most intense character. It is oftener
limited to one ovary, though it may implicate both. Like all
ovarian pain, it frequently extends down the corresponding thigh.
There is no chill, no fever, and no constitutional disturbance.
The paroxysms come on without premonition, and ordinarily
leave quite as suddenly. This is characteristic of neuralgias
in general.
Diagnosis. The absence of constitutional disturbance, the
erratic character of the pain, the diathesis of the patient, and the
absence of sequelæ will differentiate the condition from ovaritis.
It may be mistaken for hysteralgia or neuralgia of the uterus.
The latter affection is due, in at least ninety-five per cent. of all
cases, to fluid finding its way into the uterine cavity through the
cervix. The pain resulting from hysteralgia is more central,
and is not of the peculiar sickening nature which character-
izes all ovarian lesions.
Treatment.-The curative treatment must be directed to the
diathesis. If there is anemia or chlorosis these should receive
attention. Nutritious food and proper exercise are important.
Any sexual irregularities should be corrected. Nearly all neu-
ralgic patients are exceedingly sensitive to sudden temperature
changes, and, therefore, should go warmly clad.
Ludlam re-
commends that the lower part of the abdomen be protected by
an extra layer of flannel.
During the paroxysm the pain is to be relieved by the hot
douche, or sitz-bath. Hot external applications are exceedingly
gratifying. If the rectum is distended with fecal matter it should
be emptied. During the interval between the paroxysms a gal-
OVARIAN CONGESTION AND NEURALGIA.
767
vanic current of from fifteen to twenty milliampères, used twice
or three times a week, will often put a stop to the attacks. It
relieves the congestion of the ovary, which is so frequently
present, and acts as a local sedative.
Therapeutics of Ovarian Congestion and Neuralgia.
Apis mel.-Stinging pains in ovaries; enlargement of the
right ovary, with cough; aggravation after sexual intercourse.
Bryonia. Soreness of right ovary, causing irritation and
dragging pains, extending down the thighs; ovaritis with rheu-
matic affections; shooting pains extending toward the hips;
all symptoms aggravated by motion.
Belladonna.-Enlargement of the right ovary, with pressure
downward, as if everything would drop out of the vulva; pains
come and go suddenly, and are circumscribed, stabbing or dart-
ing in character; CEREBRAL DISTURBANCE AND SPASMS.
Naja. Ovarian neuralgia, with violent palpitation of the
heart; cramp-like pain in left ovary; thin, whitish leucorrhea;
languor and fatigue; organs seem to be drawn together, especially
the ovaries and heart.
Colocynth.-Stitches in ovaries; diarrhea; colic; pressure in
abdomen; intense boring pain in ovary, causing her to draw up
double.*
Cimicifuga. Ovarian irritation with irritable uterus; hysteri-
cal symptoms; rheumatism; dysmenorrhea or amenorrhea.
Bromide of ammonium.-Ovarian neuralgia; uterine hemor-
rhage from ovarian irritation or inflammation; dull, constant
pain and hard swelling in left ovary.
Hamamelis. Ovaritis following traumatism; soreness of
ovaries extending all over abdomen; ovarian affections, with
swelling and tenderness, worse at time of menses.
Lilium tig.-Stinging, darting, cutting pains in left ovary,
with sensation of swelling and tenderness on firm pressure; sym-
* "The character of the pain in the colic of Colocynth may be transferred else-
where. I remember once of curing a lady of ovarian colic, from which she had suffered
for three years, with colocynth. The pains were griping, and were relieved by bend-
ing double. There were no organic changes. Two cases of ovarian tumor have been
reported as cured by colocynth administered on this symptom."-Farrington.
768
A TEXT-BOOK OF GYNECOLOGY.
pathetic cardiac disturbances; pain extends down corresponding
thigh.
Ustilago.-Pain in right ovary, with metrorrhagia; burning
pain in the ovaries shooting down the limbs, especially the left;
neuralgic pains.
Iodium.-Chronic congestion, with induration and enlargement
of ovary; pressing, dull, wedge-like pain from right ovary to
uterus and through sexual organs; great sensitiveness of right
ovarian region during or after menses; atrophy with sterility.
Consult:-Gelsemium, cactus grand., cantharis, graphites, lache-
sis, ferrum, platina, mercurius, and mag. phos.
CHAPTER L.
ECTOPIC PREGNANCY.
Definition.-Dr. Robert Barnes originated the term, ectopic
pregnancy, to signify the development of the impregnated ovum
at some point without the uterine cavity. I adhere to this term
because, as suggested by Tait, "it gives a convenient and very
complete definition without expressing any theoretical explana-
tion of the condition." Other terms which have been put forth
to signify the accident are, extra-uterine pregnancy, and extra-
uterine gestation.
A careful review of modern medical literature will clearly
indicate the importance of the subject. I know of no trustworthy
statistics showing the relative frequency of ectopic pregnancy as
compared with normal gestation.* Of course, data of the kind,
were they accessible, would indicate a very small proportion of
ectopic pregnancies as compared with normal intra-uterine ges-
tation; nevertheless, the accident is not an infrequent one, as
every specialist who has to do with abdominal surgery well
knows.
In reviewing the literature of ectopic pregnancy one is almost
overwhelmed with its vastness. The last ten years, and espe-
cially the last five, have been most prolific ones in the creation
of a special literature treating of the accident. Indeed, it seems
almost useless to undertake, in a short chapter, to 'present
even a resumé of it; and by some it may even be urged that
the subject does not belong to gynecology at all. I cannot
share this view. It belongs most decidedly and emphatically
to the abdominal surgeon whether his line of work is in the
direction of gynecology or of obstetrics. I think that most
obstetricians will admit that gynecology has done much more
* Dr. Joseph Price (American Journal of Obstetrics, December, 1892) presents
statistics bearing upon this point, but he himself admits that they are valueless.
49
769
770
A TEXT-BOOK OF GYNECOLOGY.
toward the development of abdominal surgery than has obstet-
rics. I therefore deem no apology necessary for including in this
work a chapter devoted to ectopic pregnancy.
Varieties. Much confusion has been created by the innumer-
able subdivisions and varieties presented by various authors.
Tait, with his usual clearness of conception and love for sim-
plicity of classification, presents the following:-
SCHEME OF ECTOPIC GESTATIONS (IN TUBO-OVARIAN TRACT).
I.—Ovarian, possible but not yet proved.
II.—Tubal, in free part of tube, is (a) contained in tube up to fourteenth week, at
or before which time primary rupture occurs, and then the progress of the
gestation is directed into either-
(6) Abdominal or intra-peritoneal gestation, uniformly fatal (unless
removed by abdominal section), primarily by hemorrhage, sec-
ondarily by suppuration of the sac and peritonitis; or,
(c) Broad ligament or extra-peritoneal gestation. This may—
(a) Develop in the broad ligament to full time, and be removed
at viable period as living child;
(6) Die and be absorbed as an extra-peritoneal hematocele ;
(c) Die and suppurating ovum may be discharged at or near um-
bilicus, or through bladder, vagina or intestinal tract;
(d) Remain quiescent as lithopedion;
(e) Become abdominal or intra-peritoneal gestation by secondary
rupture;
III.-Tubo-uterine or interstitial is contained in part of tube embraced by uterine
tissue, and, so far as is known, is uniformly fatal by primary intra-perito-
neal rupture (as b) before fifth month.
While the foregoing classification possesses the merits of sim-
plicity, it is necessary to state that it is not in harmony with the
teachings of most modern authorities. Tait admits the possi-
bility of ovarian pregnancy, but claims that its existence has not
yet been proved. On the other hand, the majority of writers
accept the recorded testimony of Parry and others, as proving
conclusively that ectopic pregnancy may be located within the
ovary. Again, the scheme implies the inevitable rupture of the
tube before the fourteenth week of gestation; that it is impossi-
ble for pregnancy within the tube to progress to term without
rupture in one of the directions indicated. In refutation of this
statement many cases are recorded showing that it is entirely
possible for gestation to continue to full term without such rup-

ECTOPIC PREGNANCY.
771
ture. Pozzi states that at least twelve cases of tubal pregnancy
at term are known. Finally, the teaching that all cases of
abdominal pregnancy are secondary, i. e., result either from
rupture of the Fallopian tube directly into the abdominal cavity,
or rupture of the tube first into the folds of the broad ligament
.and then into the abdominal cavity, is contended against by
some of the best and most original investigators. Tait bases
his assertion, first of all, upon his large experience as an opera-
A.
a
FIG. 178.
B.
a
DIAGRAMMATIC SECTION OF FALLOPIAN TUBE, REPRESENTING THE TWO DIREC-
TIONS OF RUPTURE.
A. Into the peritoneal cavity. B. Into cavity of the broad ligament. a. Clot at point
of rupture. b. Wall of Fallopian tube. c. Cavity of the broad ligament, with
folds separated by hemic effusion, a. (Tait.)
tor, which, it will be admitted by all, is most valuable evidence.
He maintains that the peritoneal cavity is inimical to the life of
an ovule, whether impregnated or not; that the serous mem-
brane will quickly digest and absorb an ovule or early ovum,
which comes in contact with its surface. It is, then, according
to Tait, both a physiological and a pathological impossibility
for an abdominal pregnancy to have its origin in this way.
Other observers, on the contrary, teach that it is not only en-
772
A TEXT-BOOK OF GYNECOLOGY.
tirely possible, but altogether probable, that the spermatozoa
and ovules may remain in the peritoneal cavity for a long time
without losing their vitality.
This much in the way of introduction and to guard the reader
against accepting in toto the teachings of Tait. Although Tait
speaks dogmatically, he has the right so to do. His experience
as an abdominal surgeon is both unique and remarkable. He
does not reason from the standpoint of a theorist, but rather
from that of one who is thoroughly familiar with his premises.
If, then, we accept the classification given, we have to do with
but three primary varieties of ectopic pregnancy—ovarian, tubal,
and tubo-uterine or interstitial. The secondary varieties are,
abdominal, and intra-ligamentary.
For all practical purposes this classification is sufficient. In
dealing with suspected ectopic pregnancy, it is quite enough,
during the early period of gestation, for the clinician to locate the
fetus without the uterine cavity. Nicety of diagnosis, as regards
its exact location, is insisted upon by the "arm-chair" theorist
rather than by the practical surgeon.
Etiology. The greatest confusion prevails regarding the
causes of ectopic pregnancy. This is not strange, inasmuch as
many points pertaining to the physiology of normal menstrua-
tion and conception are as yet unsettled. Tait teaches that the
uterus alone is the seat of normal menstruation and conception;
that the ciliated lining of the Fallopian tubes prevents sperma-
tozoa from entering them and facilitates the progress of the ovum
into the uterus; and that the chief object of the plications and
crypts of the uterine mucous membrane is to lodge and retain
the ovum until it is impregnated, dies, or is discharged. Any-
thing, therefore, which interferes with the function of the cilia
of the tube may not only interfere with the passage of the
ovule into the uterine cavity, but may permit spermatozoa to
enter the tube and impregnate the retained ovule.
Bland Sutton* holds this view to be mere speculation, though
admitting that it contains some elements of truth. Sutton, how-
ever, maintains that it does not explain all cases. He contends
* London Lancet, February, 1891.
ECTOPIC PREGNANCY.
773
also that the usually accepted doctrine that the tubes are no1-
mally the meeting place of the ova and the spermatozoa in the
human family is pure conjecture. He has devoted much thought
and research to the subject. "In the first place," he says, "salpin-
gitis so severe as to promote destruction of the tubal epithelium
causes such profound changes in the tubes as to lead to stricture
and complete occlusion of the abdominal ostia. It is exceed-
ingly rare to meet in tubes denuded of their epithelium patent
abdominal ostia." He further affirms that a careful microscopic
examination of several specimens of very early tubal pregnancy
failed to disclose any evidence of loss of epithelium, or of old
salpingitis.
While in the light of the present conflict of opinion, due mod-
esty of opinion regarding the causes of the accident is most
becoming, the probability of preëxisting tubal disease acting
as a causative factor, in at least a goodly number of cases, must
be admitted. Ectopic pregnancy occurs oftener in women who
have never had children, or who, after having had one or more,
have gone for a long time without again becoming pregnant.
There is, in the language of a well-known writer, a seeming
"inaptitude" for conception, and a careful inquiry into the history
of these cases will often elicit preëxisting symptoms of more
or less pelvic distress, which are at least suggestive of tubal
disease.
To make ectopic pregnancy possible, the spermatozoa must
find their way beyond the uterine cavity into the Fallopian tube,
for of course it is most improbable that an ovule after impreg-
nation will pass from the uterine cavity again into the tube.
This much is certain, and from a practical standpoint it matters
but little whether the point of contact of the spermatozoa and
the ovule is within the tube, the ovary, or the abdominal cavity.
Any disease interfering with the passage of the ovule into the
uterine cavity will, therefore, predispose to ectopic pregnancy.
Of the various affections, preëxisting inflammation, especially
salpingitis, is undoubtedly the one most frequently responsible
for the accident. It is not difficult to comprehend an occlusion
of the tube sufficiently great to prevent the passage of the ovule
into the uterine cavity, thus causing it to lodge at some point
774
A TEXT-BOOK OF GYNECOLOGY.
within the tube, yet which would admit of the passage of sper-
matozoa upward. The mucous membrane of the tube is very like
that of the uterus, and since the ovule cannot find its way into
the uterine cavity, it accommodates itself to the unnatural site,
the Fallopian tube making a vicarious effort to care for it.
To conceive of other causes than inflammation as giving rise
to the accident, requires no great stretch of the imagination.
The effect of moral and mental emotions in arresting the down-
ward progress of the ovule is at least worthy of consideration.
When it is remembered that excessive joy, grief, or fright may
arrest or bring on menstruation, may arrest labor pains or pre-
cipitate labor, it is not difficult to comprehend that such emotions
may arrest the ovule at any point within the genital tract, or,
indeed, may so reverse the action of the cilia as to convey sperm-
atozoa entirely through the Fallopian tube into the abdominal
cavity. Nor must we ignore the part played by traumatism, by
uterine displacements, by tumors of various kinds, and, indeed,
by those blood changes which so often exert a potent influence
for evil upon all of the pelvic organs.
Ectopic pregnancy may complicate normal pregnancy. Two
interesting instances of this kind have recently been recorded.
Hertzfeld delivered a woman, aged thirty-three, of her third
child. The unusual size of the abdomen after labor led to the
detection of a second living fetus without the uterine cavity.
Laparotomy was performed, and the child, which died before the
operation was commenced, extracted. Hertzfeld considered this
to be a case of true ovarian pregnancy, basing his belief upon the
fact that the right tube presented no evidences of solution of
continuity. The funis was attached to the uterine annexa, and the
appendages of the opposite side were in every respect normal.
Worrall † removed, at the Sidney Hospital (N. S. W.), a fetus
weighing nearly five pounds from a woman whose uterus con-
tained a living child. The operation precipitated a miscarriage,
both children perishing, though the mother recovered.
Pathology.-Pathological changes will vary according to the
location of the fetus. The uterus in all cases takes on a
* Le Bulletin Médical, Paris, April, 1891.
† Medical Press and Circular, London, March, 1891.
an in-
ECTOPIC PREGNANCY.
775
creased vascularity, and its mucous membrane, in anticipation of
normal pregnancy, forms an imperfect decidua. The nearer the
ectopic pregnancy is located to the uterus the more marked will
be the changes within this organ. Thus, in interstitial pregnancy
the walls of the corresponding side become decidedly thickened,
and the whole organ is markedly increased in size. In Fallo-
pian pregnancy, on the other hand, and especially if the ovum is
lodged near the fimbriated extremity of the tube, the increase in
the size of the uterus is not so great. Admitting the possibility
of ovarian pregnancy, it is probable that, were it to occur, the
vascularity of the uterus would be even less than in Fallopian
pregnancy proper. In all forms of ectopic pregnancy the size
of the uterus never corresponds to the period of gestation,
although it always undergoes certain hypertrophic changes. In
the early months of gestation a corpus luteum is usually present.
Strangely enough, it is sometimes located in the opposite ovary.
In abdominal pregnancy the sac may be composed either of the
ovular membranes alone, or in addition to these an adventitious
membrane, the result of peritoneal irritation. The modus oper-
andi of the formation of this adventitious membrane does not
differ materially from that enclosing an intra-peritoneal hemato-
cele due to any cause.
In abdominal pregnancy, whether primary or secondary, the
fetus is sometimes found without any encysting membrane of
any sort. It is claimed by Tait that this form of pregnancy,
i. e., ectopic pregnancy within the free peritoneal cavity, is of
exceedingly rare occurrence; that a rupture into this cavity,
whether primary from the tube or secondary from the folds of
the broad ligament, is almost invariably fatal unless an operation
is at once resorted to. As an exception to this rule he cites the
now famous Jessop case, in which the fetus was not encapsulated,
but was absolutely free in the peritoneal cavity. In Jessop's case,
Tait believes that the ovum was primarily within the Fallopian
tube; that a rupture occurred at the tenth week, the ovum
escaping into the right broad ligament; and that a secondary
rupture took place at the seventh or eighth month, the fetus
then escaping into the peritoneal cavity, where it continued its
life amongst the intestines. The placenta was found "plastered
776
A TEXT-BOOK OF GYNECOLOGY.
over the pelvic contents." Instances where the fetus is found
in the free peritoneal cavity with absolutely no investing mem-
brane are not of common occurrence. I think, however, that
the case of my own, recorded on page 794, can be placed side
by side with Jessop's case.
The placenta may be attached to any, or, indeed, to all of the
pelvic and abdominal organs. In broad ligament cysts it is
often attached to all of the pelvic contents; at other times it
may be found in intimate contact with some portion of the ab-
dominal walls, the intestines, or the omentum. In my own
case of intra-peritoneal pregnancy, it was utterly impossible to
define its attachments. The position of the uterus will depend
upon the location of the ectopic cyst: When within the folds of
the broad ligament it is pushed to the opposite side and up-
wards; when in the cul-du-sac of Douglas it is carried forward
and above the pubes; and in the rare instances in which the cyst
is located in front of the uterus, the organ is pushed backward.
After the death of the fetus the cyst and its contents take on
marked changes. In the vast majority of cases the fetus under-
goes decomposition and suppuration. Occasionally, however,
the liquor amnii is absorbed and the cyst shrinks. The fetus
may also undergo calcareous degeneration and become converted
into a lithopedion; it may be transformed into a peculiar mat-
ter termed adipocere; or it may become mummified and indu-
rated from absorption of its fluids. In rare instances it remains
for an almost indefinite period unchanged. When the cyst
undergoes degeneration it usually becomes attached to some
of the surrounding organs; if to the vagina or bladder or the
intestinal canal, its contents may be discharged through them
after disintegration, or they may escape externally through the
abdominal wall.
It is claimed by Tait that in tubo-interstitial pregnancy rup-
ture invariably occurs into the peritoneal cavity. The case
coming under my own observation, whose record I append to
this chapter, is, I believe, one of interstitial pregnancy in which
the rupture occurred into the uterine cavity. Similar cases
are recorded by Parkes, Monteil, Hodge, Mundé and Thomas.
Symptoms. In by far the larger number of instances the
existence of ectopic gestation is not suspected until the symp-

ECTOPIC PREGNANCY.
777
toms of rupture present themselves. Very pretty clinical pictures
of the early symptoms are put forth in most of the text-books,
FIG. 179.
A UTERUS AND ITS APPENDAGES, SHOWING GREAT DILATATION OF THE RIGHT
FALLOPIAN TUBE, WHICH CONTAINS A FETUS OF ABOUT THE THIRD
MONTH. (Museum R. C. S. Photographed by the Author.)*
which, if in harmony with the facts, would enable the physician
to diagnose ectopic gestation with but little difficulty. Unfor-
*"From a woman, aged 22, admitted into hospital with severe pains in the hypo-
gastrium, of a month's duration. Had menstruated regularly. A hypogastric tumor
was discovered; it appeared to contain fluid and to be surrounded by large pulsating
vessels. Because of the peculiar discoloration of the inner aspect of the vulva, preg-
nancy was suspected. The tumor was tapped per rectum with an aspirator, and a
pint of bloody fluid was thus removed. A styptic solution was injected to control hem-
orrhage and at once drawn off. The patient died suddenly four days later, having
passed a decidua on the third day. Blood was found diffused over the peritoneum
and issuing from an aperture in the upper part of the back of the tubal cyst."-
Dr. C. H. F. Routh.

778
A TEXT-BOOK OF GYNECOLOGY.
tunately, clinical manifestations often occur with an obstinate
disregard for set rules. This is preeminently true with the
accident under consideration. A careful review of the clinical
history, after rupture, will usually disclose the preexistence
of more or less pelvic distress associated, possibly, with
amenorrhea or irregular hemorrhages from the uterus; yet how
FIG. 180.
4692
A UTERUS WITH THE FALLOPIAN TUBES AND OVARIES.
The right tube is laid open and contains a fetus about an inch in length, with the
extremities just budding. There is a large corpus luteum in the right ovary
which is not shown in the illustration. (Museum R. C. S. Photographed by
the Author.)
many women suffer from quite as much distress and quite as
decided irregularity of the menstrual function because of causes
other than ectopic gestation. It must, therefore, be understood
that what is said regarding the symptomatology during the early
months, and up to the period of rupture, is subject to innumer-
able exceptions. The symptoms may, however, be looked for
in something like the following order :-

ECTOPIC PREGNANCY.
779
1. Very often a considerable period of sterility followed by
general and reflex symptoms of pregnancy.
2. Associated with the general and reflex symptoms of preg-
nancy are those of disordered menstruation-usually irregular
uterine hemorrhages attended by severe pelvic pain.
FIG. 181.
A UTERUS WITH ITS APPENDAGES.
The fimbriated extremity of the left Fallopian tube is dilated into a thick-walled cyst
two inches in diameter, which contains a fetus three-quarters of an inch long,
with its membranes and placenta. The right ovary is cystically degenerated.
Covering the peritoneum which invests the back of the uterus is a thick layer of
decolorized fibrin which is partially turned down. (Museum R. C. S. Photo-
graphed by the Author.)*
3. Symptoms of pelvic inflammation, especially marked by
tenderness in one or the other iliac region. The tender area
is frequently the seat of irregular spasmodic pains.
* "From a lady, aged 31, the mother of three children. Four months before her
death she ceased to menstruate; two months later an attack of severe hypogastric
pain and collapse occurred, and in eight days a perfect decidua was discharged.
This was followed in a few days by a second attack of pain in the hypogastrium, and
a swelling above and to the left of the vagina was detected. She died within ten
minutes of a third attack. Three thin layers of coagula were found in Douglas's
pouch: the deepest, displayed in this specimen, most probably represents the first
attack of hemorrhage; the middle layer was decolorized, but soft, and may have
been the result of the second attack; the third was soft and dark red, evidently quite
recent." (See "Trans. Obstet. Soc.," Vol. xxi, p. 169.)-Alban Doran.
780
A TEXT-BOOK OF GYNECOLOGY.
4. The presence of a pulsating tumor in the region of one or
the other broad ligament, which is dense, sensitive and continues
to grow.
5. Lateral displacement of the uterus which is slightly en-
larged but empty.
6. An attack of severe pain in the pelvis followed by shock,
collapse, and all of the symptoms of hematocele.
7. Renewed uterine hemorrhage with the expulsion of the
decidua, wholly or in part.
A clinical history such as the foregoing would, if presented
entire, make the diagnosis very certain. I know of no means,
however, whereby the average woman, otherwise healthy, can be
made to consult her physician previously to the period of rup-
ture, much less to subject herself to a careful physical examina-
tion. If she be wise enough to adopt such a course, and there
should be found at one side of the uterus a gradually growing
tumor, possessing the characteristics given and attended by the
symptoms enumerated, the patient should at least be carefully
watched.
The condition most liable to be confounded with early ectopic
gestation is a retroflexed pregnant uterus. Jaggard * reports a
case of this kind in which the vaginal portion of the cervix
was so much elongated, and the lower uterine segment so thin
and compressible, as to occasion great doubt. To add to the
confusion there was pain, hemorrhage, and the expulsion of a
supposed decidua. The genu-pectoral posture cleared up the
diagnosis. Had the fundus been adhered the confusion would
have been still greater.
If the life of the fetus is not destroyed by the rupture, or if it
continues to grow in the region primarily located without rup-
ture, the symptoms will become more marked as time progresses.
After the heart sounds are heard there is, of course, no longer
any doubt as to the existence of pregnancy; it then remains
only to determine its variety.
As gestation advances the usual signs of pregnancy become
more distinct. Irregular uterine hemorrhage may continue,
especially if the decidua has not been entirely thrown off, for an
* Journal Am. Med. Ass., January, 1891.
ECTOPIC PREGNANCY.
781
indefinite period. The fetal heart sounds are often intensified
because of the thinness of the intervening tissue. For the same
reason the fetal movements are felt with greater distinctness than
in normal pregnancy. After rupture, the spasmodic pains usually
disappear for the time being, to recur, if the ovum survives, at a
later period. They become unusually severe as gestation ap-
proaches term.
Physical exploration will reveal the uterus enlarged, but the in-
crease in size does not correspond to the period of gestation.
The cervical changes, although marked, are not as decided as in
normal pregnancy. The entire organ is usually displaced later-
ally, upward, and forward. A tumor will be found in the poste-
rior cul-de-sac, and it is often possible to outline distinctly the
fetal parts through the posterior vaginal wall.
Upon inspection the absence of symmetry of the abdomen is
very noticeable-the enlargement being greater upon one side.
The increase in the transverse diameter is especially prominent.
Palpation will indicate the superficial location of the fetus,
though a reliance upon this sign is sometimes misleading. There
is in this connection one source of error, alluded to by Parry and
Tait, which may make the diagnosis very uncertain. I refer to
extreme thinness of the abdominal and uterine walls in otherwise
normal pregnancies. Such a case recently passed under my
observation. The patient, æt. 27, was unmarried and had a
kyphotic pelvis. The tissue intervening between the examining
hand and the fetal parts did not seem much thicker than parch-
ment. The distorted pelvis caused an irregularity in the abdominal
enlargement which added greatly to the confusion. I first saw
the case at the beginning of the eighth month of gestation, and
remained in doubt as to the actual location of the fetus for four
weeks, though making repeated examinations. At the beginning
of the ninth month the uterine tissues began to increase in thick-
ness, and I succeeded in reaching the presenting part through
the cervix, which, of course, determined beyond all doubt the
presence of the child within the uterus.
In order to emphasize the importance of this point I cannot
do better than quote in detail from Lawson Tait.* He says:
* "Diseases of Women and Abdominal Surgery."
782
A TEXT-BOOK OF GYNECOLOGY.
"This condition of extreme thinness of the uterine wall, in a preg-
nancy perfectly normal in every other respect, is a point which has not
yet received the notice it deserves. It is, however, of sufficiently
common occurrence to be a source of difficulty and danger, and,
therefore, I propose to say here what I have noticed about it, in the
hope that it may draw the attention of some one engaged in obstetric
practice who may be able to investigate it more fully. I can now
recall eight cases in which I have been consulted concerning a sup-
posed extra-uterine pregnancy, yet in which there was only an extreme
thinness of the uterine walls. I have no record of three of the cases,
but of the others I have more accurate data than mere recollection.
The features of all of them have much in common, and the known
histories of four quite establish this. The ordinary symptoms of preg
nancy were present in all of them, and in only one was there any
doubt as to its existence. The question generally was: Is the child
in the abdominal cavity? and sometimes I had great difficulty in per-
suading the gentlemen who brought the patients to me that the posi-
tion of the child was normal. Save in one case that seen by me
with Dr. Whitwell, at Shrewsbury—there was a marked absence of the
liquor amnii, so that the movements of the child could be seen and
felt in a most striking manner. In the pelvis the finger came upon
the presenting part of the fetus, as if it lay immediately under the
mucous membrane; and it was only on very careful investigation that
the attenuated cervix uteri could be made out, spread over the body
of the child.”
At the end of the normal period of gestation in ectopic preg-
nancy a spurious labor usually sets in. The pains are so
much like those of natural labor that nothing wrong may be
suspected until a physical examination reveals the unnatural
state of affairs. They are intermittent and periodical in charac-
ter. This spurious labor varies in duration from a few hours to
two or three weeks. Occasionally it does not occur, but in most
instances a careful inquiry into the history will reveal the fact
that pains not unlike those of labor were present at or about
the time fetal movements ceased to be felt. The pains vary
greatly in severity, and it is their occasional trivial and fugitive
character that causes the patient to forget ever having had them
unless her memory is especially jogged. In most instances,
however, they are sufficiently severe to cause most excruciating
suffering.
ECTOPIC PREGNANCY.
783
A hemorrhage from the uterus usually accompanies the
spurious labor. It is followed by a discharge much like that of
the lochia.
It is probable that the fetus lives but for a short time after
the occurrence of the false labor, and its death is to be ac-
counted for by the changes which occur in the utero-placental
circulation. Nature, even when working under great disadvan-
tages, makes an effort to observe certain fixed laws. The time
has come for fetal expulsion and cessation of the utero-placental
circulation. The fetus, of course, cannot be expelled spontane-
ously, but the placental circulation can be cut off, and is, though
gradually. How long after the full period of development the
child can live is a mooted question; it is not improbable that its
life may be maintained for some time after the end of normal
gestation is reached.
After the death of the fetus it may undergo any of the changes
which have been indicated under the head of pathology, though
rarely does the system tolerate its existence for any length of
time. An effort is usually made, sooner or later, to expel it
through inflammation and suppuration. It is true that an en-
cysted fetus is not incompatible with life, and indeed, with a fair
degree of health and comfort. The condition is, however, one
never devoid of danger, for with the slightest provocation the
cyst is liable to become inflamed and to undergo suppuration.
In those rare instances where the fetus has been carried for
years it is transformed into a lithopedion or undergoes calcareous
degeneration.
Diagnosis.-Ectopic gestation is to be differentiated from—
Acute pelvic cellulitis and peritonitis;
Pelvic hematocele due to other causes than ectopic pregnancy;
Conception in a rudimentary horn of a double uterus;
Pelvic abscess;
Uterine fibroids.
In acute pelvic cellulitis and peritonitis no history of pregnancy
will be elicited. There will be a history of inflammation, with
the sudden formation of a tumor within the pelvis. The pecu-
liar, spasmodic, colicky pains so characteristic of ectopic preg-
nancy are wanting; there are no mammary changes and the
uterus is but slightly enlarged.
784
A TEXT-BOOK OF GYNECOLOGY.
In pelvic hematocele due to causes other than ectopic preg-
nancy, it will many times be utterly impossible to make an abso-
lute diagnosis. The absence of all preexisting signs of preg-
nancy will at least lead the examiner to suspect that the source
of the effused blood is some other than a ruptured extra-uterine
pregnancy cyst, but, as I have already endeavored to show,
these signs and symptoms are so often wanting in ectopic gesta-
tion as to make their absence of little value in determining the
actual cause of the hematocele.
When conception occurs in one side of a double uterus cer-
tainty of diagnosis is oftentimes utterly impossible. The changes
in the uterus are very much greater than is the case in ectopic
pregnancy proper, and our chief reliance will have to be placed
upon these changes.
In pelvic abscess, due to causes other than suppuration of an
ectopic pregnancy cyst, there will be a clinical history of the
primary lesion-inflammation, pyosalpinx, etc.
In uterine fibroids there is no history of pregnancy. The
tumors are painless. Their presence does not ordinarily give
rise to spasmodic, colicky pains, and they do not grow with
the same rapidity as does a cyst due to ectopic pregnancy.
Should fibroids complicate intra-uterine pregnancy the confusion
may be very great (v. p. 611).
It is not often possible to determine the variety of ec-
topic gestation. There are certain peculiarities, however, per-
taining to each variety which are worthy of consideration. In
abdominal pregnancy, for instance, the uterus will be found en-
tirely empty. Its size will not be increased as markedly as in
the other two forms, and the child can be moved about in the
abdominal cavity very much more readily than is the case when
enveloped either by the tube or the folds of the broad ligament.
In tubal pregnancy the enlargement will be more unilateral
and the tumor somewhat separated from the uterus. Ballotte-
ment is much more distinct than in the abdominal variety. In-
terstitial pregnancy is the rarest of all forms. It gives rise to an
irregular enlargement of the uterus and is intimately connected
with it, though the organ will be found empty.
The diagnosis, after the death of the child, may present many
ECTOPIC PREGNANCY.
785
difficulties unless, indeed, suppuration has already occurred
and pieces of the fetus have been expelled through the bowel,
vagina, abdominal wall, or bladder. The history of the case
will ordinarily afford much valuable information. Patients
believe themselves to have been pregnant, and, if they also re-
late a history of spurious labor followed by cessation of the fetal
movements, the diagnosis is pretty certain. After the death of
the fetus the abdomen decreases in size and the cause of the
enlargement may be attributed to some other condition—ova-
rian cyst, fibroid tumor, cancer, etc. While the examiner should
rely much more upon physical signs than upon the history
given by the patient the most careful physical exploration
may fail to reveal the actual condition. If the symptoms of sup-
puration present themselves, the pus should be evacuated as
soon as expedient and the remains of the fetus removed. This
will, of course, clear up the diagnosis, and in most instances
promote a cure as well.
Prognosis.-Ectopic pregnancy is always a serious condi-
tion. It is said that the abdominal variety is the most favorable
of all, but even here the prognosis is quite bad enough. If
rupture does not occur before the fourth month, there is strong
probability that gestation will continue until term, at which time
there is again the greatest liability to rupture. In the event of
rupture, if it occurs in the free peritoneal cavity, the larger
proportion of cases die as a result of the hemorrhage unless
operative interference is immediately resorted to. Rupture
into the folds of the broad ligament, as we have seen in deal-
ing with extra-peritoneal hematocele, is a much less fatal acci-
dent.
After the death of the fetus, suppuration and blood-poison-
ing usually terminate life. It is true that a patient may carry
an extra-uterine fetus for an indefinite length of time without
serious inconvenience or distress, but this is a rare exception
to the general rule, and she is never free from danger while so
doing; a slight accident of any kind may excite suppuration.
It is true also that spontaneous recoveries are reported after
suppuration sets in, the fetus being expelled piecemeal through
some of the avenues already mentioned. That a few recoveries
50
786
A TEXT-BOOK OF GYNECOLOGY.
under these circumstances should have taken place only proves.
the physical endurance of some women; it certainly does not
justify an expectant plan of treatment after the diagnosis has
been made.
Treatment. With the frightful mortality attending unmo-
lested ectopic gestation confronting us, there is little need of argu-
ment in favor of some form of operative treatment. Death from
hemorrhage, peritonitis, septicemia or exhaustion, is the termina-
tion in such a very large proportion of cases as to have caused
a general acceptance of the proposition laid down by Werth* to
the effect that "Extra-uterine pregnancy is a malignant neo-
plasm and should be treated as such." A woman's life is in
jeopardy as long as she carries an ectopic cyst, and the danger
begins from almost the very inception of pregnancy. Even
after the fetus has been transformed by degenerative changes
into an "inert mass," the danger is very great. The treatment,
therefore, is simply reduced to a question of method and time for
operative interference.
The conflict of opinion that exists among modern authorities
has to do largely with the management of the gestation when
the patient's life is not immediately threatened by rupture or
hemorrhage. In the treatment of ruptured cyst with active
hemorrhage the dictum of Stephen Rogers, enunciated as long
ago as 1867, to the effect that "The peritoneal cavity must be
opened; the bleeding vessels must be ligated," † has become the
guiding principle of all surgeons.
* "Extra-uterine Gestation and the Early Signs which Characterize it.”
† I desire again to call attention to the fact that the credit of this dictum belongs
to the late Stephen Rogers, an American surgeon. The quotation given is taken
from the "6 Transactions of the American Medical Association" for 1867, the essay
(which fairly teems with suggestions which have now become recognized surgical
principles) being reprinted in pamphlet form. In reviewing Lawson Tait's "Lec-
tures on Diseases of the Ovaries," in 1888, I called his attention to Rogers's essay.
A copy of the review falling into Mr. Tait's hands led him to write me, thanking me
for calling his attention to the essay of Rogers, of which he had never previously
heard. I sent him my only copy, but he does not allude to it in his "Diseases of
Women and Abdominal Surgery," which was given to the profession early in 1889,
except in a quotation taken from Parry. Parry gives Dr. Herbert (also an American
surgeon) the credit for first suggesting gastrotomy to save a woman dying from
early rupture of the cyst. Whether Mr. Tait has elsewhere acknowledged the bold
teaching of Rogers (and it was indeed bold at that early date) I do not know. Parvin,
ECTOPIC PREGNANCY.
787
Previously to the period of rupture the questions, then, which
confront the surgeon are: Shall the abdomen be opened and
the cyst removed as soon as discovered? Shall measures be
resorted to, having for their object the destruction of the ovum ?
Or shall the pregnancy be permitted to continue to term with
the hope of delivering a living child through the abdomen?
1. Shall the abdomen be opened and the cyst removed as soon as
discovered? As has already been intimated, ectopic pregnancy
is not suspected in by far the larger number of cases until rupture
occurs. If a fairly certain diagnosis can be made of an ovum
within the Fallopian tube, or if the patient present symptoms
which in themselves give rise to suffering sufficiently great to
justify an exploratory operation, I think that the indications are
clearly to open the abdomen, and, if an ectopic pregnancy cyst
be found, to remove it at once. The possibility of the abnor-
mal gestation continuing to term without interruption is so
remote, and the maternal dangers are so great, as to make this
course almost imperative. But let the uncertainties of diagnosis
at this period be borne in mind. The surgeon who is governed
in all cases by dogmatic rules will probably more than once
open the abdomen to find that the tumor is not due to an ectopic
pregnancy, but to some other pathological condition. Since an
exploratory incision in the hands of a skilled laparotomist under
modern antiseptic methods is not a very dangerous procedure,
the mistaken diagnosis will ordinarily be followed by no bad
results; and if the local symptoms are such as to simulate
ectopic pregnancy, the disease, usually a pyosalpinx, can be
removed. After the fifth month, if the fetus is dead, I think
that an abdominal section should undoubtedly be made. There
may be some question as to the advisability of laparotomy imme-
diately after death occurs, i. e., before the cessation of the utero-
placental circulation. The majority of the authors advise
against the immediate operation because of the increased danger
from hemorrhage. In its favor there is to be said that there is
and Thomas (the last edition of Thomas & Mundé) also mention the teachings of
Rogers only in an incidental way. This rather surprises me, for, in the light of 1867,
Rogers's radical arguments show him to have been a man of clear conception and
great originality.
788
A TEXT-BOOK OF GYNECOLOGY.
much less danger from peritonitis and septicemia, and since we
have learned to control hemorrhage by gauze packing, the
danger from bleeding is reduced to a minimum. As soon
as sepsis manifests itself, an operation is not only indicated
but imperative.
I think, too, that even in those instances where the fetus has
been transformed into a lithopedion, and tolerance of it is prac-
tically established, the danger of non-interference is much greater
than is an operation for its removal. A “quiescent lithopedion,"
as is shown by Tait, Campbell, Parry, and others, is of decidedly
rare occurrence, and a woman is never for a moment safe while
carrying within her abdomen the products of an ectopic gesta-
tion.
Other considerations calling for immediate operative interfer-
ence are suppurating fetal cysts, and pregnancy in a rudimen-
tary uterine cornu. In the first instance, even though the cyst
abscess is already discharging, the processes of nature must
be hastened. In the majority of cases it is not necessary to open
into the abdomen, the fistula indicating the preferable point for
incision. When the fetus is within a rudimentary cornu the
mortality in unmolested cases, according to the statistics of
Bandl, is over seventy-seven per cent. Owing to the difficulty
of obtaining a suitable pedicle, it is best to remove the entire
uterus, as in Porro's operation.
2. Shall measures be resorted to, having for their object the de-
struction of the ovum before laparotomy is performed?
It is a
well-known fact that if the ovum perish during the early weeks of
gestation it ordinarily gives rise to no further trouble. We have
seen that it is altogether probable that when Fallopian preg-
nancy ruptures into the broad ligament, ovular death
with absorption is the rule rather than the exception.
This, at least, is the teaching of Tait and others of extended
observation. We have seen, too, that it is utterly impossible, in
by far the larger number of cases, to distinguish a broad liga-
ment hematocele due to ruptured ectopic pregnancy from one
due to other causes. Since this is the case it seems to me emi-
nently proper, when the rupture has evidently taken place into
the broad ligament, to resort to measures which tend to destroy
ECTOPIC PREGNANCY.
789
the life of an early ovum. From present data it is difficult to
estimate the value of electricity for this purpose. The accuracy
of diagnosis is ever to be questioned, even in the hands of men
whose reputation is established; yet I think that the utility of
electricity can hardly be denied in properly selected cases. I
would not use it if I thought that the ovum were still within
the Fallopian tube, for fear of inducing rupture; nor should I
use it in large ectopic cysts. I should limit its use to broad
ligament hematoceles, whether due to ectopic pregnancy
or to other causes, with a view, first, of destroying the vitality
of the ovum, and, secondly, of promoting the absorption of the
hematocele. We have in galvanism an invaluable agent for
the latter purpose, and it is reasonably certain that a strong
galvanic current passed through the tumor will also kill an early
ovum. Since this is so I cannot conceive of galvanism doing
any great amount of harm, and it may do much good. It is at
least worthy of trial.
On the other hand, I cannot conceive of anything more unsur-
gical than the destruction of the fetus by galvanism, or by any
of the methods presently to be mentioned, after the fourth
month. After this period the changes following the death of
the fetus are such as to make its destruction, to my mind at
least, a most unwise procedure.
Electro-puncture and faradization have also been used
with alleged success. Electro-puncture strikes me as a more
dangerous expedient than is exploratory laparotomy, and infi-
nitely less satisfactory. The faradic current, restricted to the
class of cases which I have described, would probably be harm-
less, though the recent experiments of A. Martin go to prove the
greater destructive properties of the galvanic current. Martin
passed a strong faradic current, and a galvanic current of fifty
milliampères, through a large number of eggs in different periods
of incubation. Eighty per cent. of those acted upon by faradism
hatched, while none treated by galvanism did so.
The injection of morphin, strychnia, ergotin, etc., and the
internal administration of iodid of potassium, mercury, and
other similar agents for the purpose of killing the ovum, have
been resorted to in the past, and are still mentioned by a few
790
A TEXT-BOOK OF GYNECOLOGY.
writers as justifiable procedures. Attention is called to them
under this head only for the purpose of condemning their use.
They are all inferior to electricity and infinitely more dan-
gerous.
3. Shall the case be permitted to continue to term with the hope of
delivering a living child through the abdomen? In considering
this question we are again confronted with the most diverse opin-
ions of men whose authority is established beyond peradventure.
It seems to me that the rights of the fetus have been in the past
too much ignored. After the fifth month there is certainly a fair
prospect of gestation continuing to term without rupture, and,
should rupture occur, the danger attending gastrotomy is not so
very much greater than is the operation previously to the acci-
dent-providing, of course, the patient is easily accessible. This
is especially true if we can convince ourselves that in all probabil-
ity the pregnancy is abdominal. Jessop, Eastman, Braun, Breisky,
Tait,* and Koeberle† have all succeeded in delivering living
children through the abdomen. In my case of intra-peritoneal
pregnancy I believe that the child could have been saved had the
operation been performed earlier. At any rate the results already
obtained force the claims of the fetus upon us after the fifth month.
During the early period of ectopic gestation the maternal dan-
gers are so great, and the chances of the ovum surviving the
period of rupture so slight, that we are compelled to ignore these
claims. After the fifth month, however, we can only look upon
any operation having for its object the inevitable death of the fetus.
as a stigma upon the obstetric art. The brilliant results obtained
by Tait and others, justify the hope that during the coming ten
years feticide, even in ectopic gestation, will be practised much
less often than formerly. Nevertheless, here, as in all branches
of abdominal surgery, fixed rules and dogmatic teaching will ever
be set aside by the surgeon whose skill and ingenuity make him
equal to any exigency or emergency. Such a one will look upon
the delivery of a living child at term through the abdominal wall,
from a living mother, as "the crowning triumph of obstetric sur-
gery."
He will not, however, when the odds are greatly
* Tait has saved three children and two mothers.
+ Koeberle saved four mothers and seven children out of nine operations.
ECTOPIC PREGNANCY.
791
against the mother, hesitate to sacrifice the fetal life for the sake
of saving hers.
The general principles to be observed in the management of
ectopic pregnancy may be summed up as follows:-
I. When life is threatened by hemorrhage from a ruptured
cyst, no matter what the period of gestation may be, the abdo-
men should be immediately opened, the bleeding point secured, and
the products of the conception removed. Immediate laparotomy
should also be resorted to if a fairly certain diagnosis can be
made previously to the fifth month; if symptoms of septicemia
present themselves at any period of gestation; if suppuration
occurs; and, finally, if the products of an ectopic pregnancy
are found in the form of a lithopedion, even though apparent
tolerance has been established.
2. We are not justified in resorting to measures for destroying
the life of the fetus except when rupture occurs into the broad
ligament previously to the fourth month, when galvanism may
be used.
3. After the fifth month if the fetus is living we are justified,
if the conditions are favorable, in temporizing, with the hope of
delivering at term a living child through the abdomen. This
with a full consciousness that many cases will present elements
of danger demanding immediate operative interference.
Technique of the Application of Electricity.-One pole is
applied as closely to the tumor as possible, either through the
vagina or the rectum. If the galvanic current is used, the
negative pole should be the direct one. A large dispersing elec-
trode is placed over the abdomen. The strength of the current
should range from twenty-five to seventy-five milliampères. The
sittings should continue for from ten to fifteen minutes, and
should be repeated every other day until the tumor ceases to
grow and diminishes in size. A sharp faradic current may be
passed for a short time after the galvanic.
Technique of Laparotomy for Ectopic Gestation.-The
general principles of abdominal section, applicable in all cases
of laparotomy, are, of course, to be observed. These have been
elsewhere discussed (Chapter XLVI), and I shall at this time
refer to a few special points only.
792
A TEXT-BOOK OF GYNECOLOGY.
Before and soon after the death of the fetus the great element
of danger is hemorrhage. In early tubal pregnancy there is no
difficulty in obtaining a pedicle, and the entire mass should be
ligatured and cut off. The abdominal wound may then be
closed either with or without drainage, as the case may require.
From the fifth month on, such a course as this is rarely ever
practicable, for it is usually extremely difficult to remove the
entire mass. If the sac can be more easily reached by making
a lateral abdominal incision this should be done. Indeed, the
lateral incision is ordinarily preferable to the central, for there is
less danger of opening into the peritoneal cavity. If it is possible
to reach the sac without invading the peritoneal cavity, Tait
recommends the following procedure:* "When the sac is
opened the fetus is to be carefully lifted out by the feet, using
great care not to lacerate the sac or abdominal wall. If the
child is living some one disengaged should take immediate charge
of it. The umbilical cord should be cut off quite close to the
placenta, the placenta squeezed as empty of blood as possible,
the sac cleansed of all blood, loose membranes, etc., and then
washed with warm water, the sutures carefully placed, the sac
again washed out with clean water by means of a siphon trocar,
and the stitches drawn tight, with a small trocar still in the wound.
The sac should then be emptied of all the water possible, the
trocar taken out with precautions against admission of air, and
the wound totally closed."
Tait thinks that this is the best method of dealing with the
placenta, and he has tried all. He has twice removed it entire,
in each case saving both the mother and child. The hemor-
rhage was controlled by perchlorid of iron. Occasionally it is
possible to secure the main vessels of the pedicle, when the
placenta should always be removed. Oftener the attachments.
are extensive, and the placenta should be left unmolested.
When the peritoneal cavity is opened into, care should be
taken not to injure the placenta in opening the sac. If it is
clear that the removal of the sac will be attended with great
difficulty it should be stitched to the abdominal wound. No
* " Extra-uterine Pregnancy," Strahan, 1889, p. III.
ECTOPIC PREGNANCY.
793
traction should be made upon the placenta and cord. The sac
may now be treated as recommended by Tait, or it may be
washed out with a 1 : 4000 bichlorid solution and packed with
iodoform gauze. The gauze can be safely left in the cavity for
three or four days. If the vagina can be easily penetrated
without injuring the placenta, a T drainage-tube may be passed
into it through the bottom of the sac. After the removal of
the gauze the cavity is kept thoroughly clean by frequent irri-
gation. The placenta is detached piecemeal and the cavity
gradually closes by granulation. A glass tube may be intro-
duced instead of the gauze.
The method of hermetically sealing the placenta within the
cyst cavity, as recommended by Tait, is unquestionably the
preferable one when it can be accomplished. By it the placenta
is absorbed without decomposition and suppuration is done away
with. Should decomposition supervene the sac can be re-
opened and the decomposed placenta removed with but little
danger from hemorrhage.
If the fetus has been dead for some time, matters are much
simplified. It is now no longer advisable to close the wound
hermetically. If placental decomposition is already established
the organ can be removed at once and hemorrhage controlled
by gauze packing. An effort should be made to remove the
entire sac. Drainage is here a sine qua non.
In those rare instances where the fetus is intra-peritoneal and
without any investing membrane, as in Jessop's case and my
own, there is no sac other than the entire abdominal cavity to
deal with. In Jessop's case the child was living and the placenta
covered the inlet of the pelvis like the lid of a pot, and
extended some distance posteriorly above the brim where it ap-
parently had an attachment to the large bowel and posterior
abdominal wall." (Strahan.) Jessop did the only possible thing
to do under the circumstances, and left it entirely untouched.
In my case, the placental attachment was quite as extensive,
involving the uterus and annexa as well as the omentum.
had to do with a large putrid mass within the free abdominal
cavity of a patient whose system was already surcharged with
septic poison. To have left it behind would have been simply
I
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A TEXT-BOOK OF GYNECOLOGY.
criminal. I therefore took away all removable sources of hem-
orrhage and septic infection. In so doing, although observing
a broad surgical principle, I had to create a precedent, for I had
not, up to the time of operating, been able to find a recorded
instance of ectopic pregnancy other than interstitial, in which
the entire uterus and annexa were removed with the fetus and
placenta.
Elytrotomy or Vaginal Extraction.-Elytrotomy in ectopic
pregnancy still has its advocates. I have had no experience
with it nor do I think that I ever shall have. The restricted
field of operation, the difficulty of controlling hemorrhage, and
the remarkable results obtained by the abdominal method will
deter me, I think, from undertaking the vaginal. I can, however,
imagine that with one inexperienced in abdominal surgery the
temptation to extract a fetus easily felt projecting into the
vagina, by elytrotomy, would be very great. Pinard's method,
as given by Pozzi,* is as follows:-
"Anesthesia; exploration of the vaginal cul-de-sac and puncture with the knife
at a point where the absence of arterial pulsation has been ascertained. Introduction
of the finger into the buttonhole for exploration, then enlargement by multiple inci-
sions, and dilatation by the use of the fingers. The hand pressed into the sac grasps
the feet and brings them to the vulva by slow and continued traction. Then the
trunk and the breech are engaged. The two arms are successively disengaged and
then the head extracted. The cord is cut and search is made for the placenta. If it
can be easily removed, it is gently detached with the fingers; if it adheres, no matter
how little, it is better to leave it. The cavity of the cyst is then washed out freely
with a sublimate solution 1: 5000, or a saturated aqueous solution of naphthol-ß. I
am inclined to think that the introduction of iodoform gauze would be preferable to
the frequent injections advised by Pinard; the gauze may be removed every three or
four days, and might be left even longer in place. If symptoms of putrid infection
appear by reason of insufficient antisepsis, continuous irrigation might be used.”
Illustrative Cases.
CASE LXXXVII.—Non-encysted Intra-peritoneal Pregnancy. Operation. Re-
covery. (North American Journal of Homeopathy for October, 1889.) Mrs. E. C.,
actress, aged 23 years, dark hair and eyes, petite and very intelligent. Patient of Dr.
Sara J. Allen of Charlotte, Michigan. Married, June, 1888, just thirteen months
previously to the operation, at which time she was menstruating regularly, but the
flow never appeared after marriage. The following November, fearing pregnancy,
* "A Text-Book of Gynecology,” p. 506.
ECTOPIC PREGNANCY.
795
she for the first time consulted a physician, who made an ineffectual effort to produce
an abortion. After a rest of four or five days she returned to the stage.
While engaged in her work as an actress, she sustained three bad falls, suffering as a
result much and continuous pain. In February of this year (1889) she had a severe
attack of peritonitis, preceded by collapse and syncope. She was confident of feeling
motion and life previously to and during this attack, notwithstanding the assurance of
several physicians who at the time examined her, that no pregnancy existed. Going
from town to town, numerous medical men were appealed to, and not in vain, to
undertake an abortion. The repeated criminal efforts were unavailing, and she, too,
became dissuaded, believing her condition to be due to other causes than pregnancy.
On the morning of July 23, Dr. Allen sent for me. I found the patient in a pre-
carious condition, with a pulse 145, and a temperature 104°. Sepsis was marked,
as was shown by the pulse, temperature, color of the skin and profuse perspiration.
The abdomen was the size of a full-term pregnancy and very sensitive; the enlarge-
ment was uniform and symmetrical. The vagina was equally sensitive, and the
patient could not tolerate an examination which was in the least sastisfactory.
I could, however, feel a large fetal head low down between the vagina and the
rectum, the sutures being felt with distinctness and the plasticity of the head easily
observed. The intervening tissues did not seem to be thicker than heavy parchment.
This examination made me mistrust an extra-uterine pregnancy, a condition which Dr.
Allen strongly suspected before my arrival, and I requested that another assistant be
secured, so that, if our suspicions were confirmed by an examination under ether, an
operation might be proceeded with. We accordingly got everything in readiness to
meet any emergency.
At 1.30 P. M. the patient was placed on the table under the influence of ether. The
head was found in the position described, evidently occupying the Douglas pouch.
The cervix was high up above the pubes, and could be dragged down but a
short distance by the volsella. The finger could be passed through the canal only to
the internal os. A probe penetrated the uterine cavity three inches. The fetal parts
could be easily detected through the thin abdominal walls, and I imagined that I
could hear the placental bruit, though I fully appreciate the deceptive nature of this
sound, especially under the circumstances with which I had to contend. Feeling
confident that the child was not within the uterine cavity, and with the concurrence
and assistance of the attending physician and Dr. J. W. Siegfried, then of Charlotte,
I prepared to open the abdomen.
Operation.-Observing antiseptic precautions as thoroughly as possible, an incision
was made midway between the pubes and the umbilicus, in the median line. I did
not make a lateral incision because the perfect symmetry of the abdomen gave no clue
as to the side upon which the sac was located-if it were upon either side. The first
stroke of the knife brought me to a membrane resembling the peritoneum as found
over adherent ovarian tumors. Catching this between two forceps and nicking it,
a stream of fluid, either amniotic or ascitic, gushed out. The abdominal walls were
quite vascular, and several catch forceps had to be applied to spurting arteries. It
now became necessary to enlarge the abdominal incision so that it extended at least
two inches above the umbilicus. The feet of the child were then grasped by the left
hand and an effort made to deliver it through the wound. This could not be done
until the head was peeled out, as it were, from the cul-de-sac of Douglas, after which
a five-pound putrid fetus, thickly covered with vernix caseosa and with the skin

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A TEXT-BOOK OF GYNECOLOGY.
broken in many places owing to the high state of putrefaction, was delivered through
the abdomen. The hemorrhage at this stage became frightful, the patient exsan-
FIG. 182.
a
b
e
THE AUTHOR'S CASE OF INTRA-PERITONEAL PREGNANCY. FETUS AND PLA-
CENTA WITH UTERUS AND ANNEXA.-(Wood.)
a. Peritoneum stripped from base of the broad ligament. b. Base of the broad liga-
ment. c. Outer border of left broad ligament d. Fundus of uterus at the point
of section e. One of the inflammatory bands extending to transverse colon. (The
omentum is not shown.)
guinated, and it was evident that something had to be done, and that quickly.
Instructing Dr. Siegfried to throw some brandy under the skin, I quickly threw
ECTOPIC PREGNANCY.
797
an elastic ligature around the entire mass and packed sponges about the pedicle.
This controlled the hemorrhage very effectually and gave me an opportunity to wash
the clots from the abdominal cavity by pouring hot water into it from a pitcher.
The next point to contend with was the management of the placenta. It was very
evident that the peritoneal cavity could not be excluded from the cyst cavity, for the
only cyst cavity that I could detect was the peritoneum, unless, indeed, the cul-de-sac
occupied by the head could be called such.
I found no traces of a gestation sac other than the attachment of the omentum to
the mass which I had included in the elastic ligature, and several bands of inflam-
matory tissue springing from the pelvis and attaching themselves to the transverse
colon. A more careful examination showed that my ligature had embraced the left
broad ligament, between whose folds the placenta was attached, the entire fundus of
the uterus and both tubes. The inclusion of the uterus could only be determined by
failure to find it in any other locality, for it was utterly impossible to distinguish or
separate the various structures of the mass; indeed, in my opinion, it would have been
the most reckless folly to have undertaken it. To detach the placenta was entirely
out of the question; to leave it within the abdominal cavity, the peritoneum being
more or less destroyed at the lower border of the broad ligament and the system
already saturated with septic material, seemed equally unsafe. I therefore transfixed the
pedicle above the ligature with a couple of Wilcox pins and cut away the entire mass
—placenta, uterus and appendages—permitting the stump to rest at the lower angle
of the wound, as in supra-vaginal hysterectomy. The omentum seemed unhealthy,
very much thickened and even gangrenous, and this too was tied and cut away.
The bands of inflammatory tissue were secured in the same way. In short both the
abdominal and the pelvic cavity were completely emptied of any tissue or substance that
could slough or decompose. The abdomen was again thoroughly washed with hot water
and sponged dry, but owing to the continued oozing of blood from the Douglas
cul-de-sac a glass drainage tube was passed into the bottom of the cavity. The
patient's condition would not permit of longer delay in contending with the
hemorrhage so the pelvis was packed with iodoform gauze, one end of which was
left projecting from the abdominal wound. The abdomen was then closed and
the stump dressed in the usual manner, when the patient was placed in bed, very weak,
but soon rallying under the influence of warmth and hypodermic stimulation.
The pulse dropped in nine hours after the operation to 116, and the temperature to
101°, without any evidences of profound shock. The temperature fluctuated between
101° and 102°, one day reaching 104° for a short time, approaching the normal about
the sixteenth day. Nourishment was freely taken and retained from the first. The
gauze was removed at the end of the second day, blood-stained but sweet. Smaller
drainage tubes were substituted from time to time, but drainage was entirely discarded
on the twenty-sixth day. The cavity was kept thoroughly clean by suction and fre-
quent washing. The pedicle and ligature were removed on the sixteenth day, the
entire cervix coming away through the vagina on the seventeenth day. This seemed
to me most unusual, and, to make sure that it was the cervix and not a decidua, I had
the mass sent to me for examination. I also had Dr. Allen make a vaginal examina-
tion before completing my record, and she reported an entire absence of the cervix.
It is probable that the elastic ligature fell below the utero-vaginal mucous membrane,
thus severing the cervix and permitting it to fall into the vagina, the fundal end of
the stump adhering to the lower end of the abdominal wound for several days longer.
Ала
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A TEXT-BOOK OF GYNECOLOGY.
The patient was able to take a drive just one month from the day of the operation
and ultimately recovered perfectly.
CASE LXXXVIII.—Interstitial Pregnancy Rupturing into Uterus. Recovery.—
Mrs. S., aged forty years; brunette; somewhat below the medium stature, and of rather a
nervous temperament, but of the finest type of womanly character. Commenced menstru-
ating at fifteen. Her only child is ten years old, and twelve months after the birth of
this child she had a miscarriage at the second month. The miscarriage was not fol-
lowed by any serious sequelæ, menstruation recurring at regular intervals, being normal
in quantity and duration the following seven years. Three years before I saw her she
had an attack of pelvic peritonitis, caused by undue exposure of some sort, which came
very near proving fatal; an inflammatory deposit was left behind which caused consider-
able pain and inconvenience. From that time on she sufferred from menorrhagia, which
at times was alarming. One year before I saw her this became so bad that she was
compelled to take to her bed and place herself under the daily attendance of Dr.
James M. Long of Coldwater, whose patient she was. The examination then made
revealed, besides the inflammatory deposit, a fibroid involving the posterior wall and
fundus of the uterus. She was very much emaciated and very anemic from the loss
of blood, but by the properly selected remedies in conjunction with daily local treat-
ment, she so far recovered, as to be able to spend a season at the Northern Lakes,
which added to the improvement already begun at home. The menorrhagia, how-
ever, remained more or less severe.
About the middle of the following January she was again taken with unusual
symptoms, which for the second time necessitated almost daily attendance. She
suffered from dull, heavy bearing-down pains in the pelvis extending to the back and
down the thighs; great lassitude, with an obstinate hacking cough; anemia from the
long continued drain upon the system; leucorrhea, with at times clots of matter and
blood in the discharges. There was no nausea or vomiting.
On the 29th of March, 1885, Dr. Long requested me to examine the case with him.
Besides the facts given above I elicited the following: The usual menstrual flow
made its appearance in January. In February she was unwell but one day, and in
March, just four weeks from the day she was unwell in February, menstruation again
appeared, and so far as quantity and duration were concerned this was the most
natural period she had had for three years. She had ceased flowing three days be-
fore I was called as counsel. I found her very much in the condition described
above. The uterus could be plainly outlined through the lax abdominal walls, ex-
tending as high up as the umbilicus, the fundus tipping backward and to the left.
There was, in the region of the left Fallopian tube, a distinct tumor about as large as
a small fetal head, with a broad base continuous with the left uterine wall. It
seemed hard and gave a perfectly resonant sound on percussion. Upon making an
examination per vaginam the cervix was found hypertrophied, elongated, and directed
forward; the os was dilated so as almost to admit the index finger, and from it there
oozed a thick, sanious discharge. As far as the finger could discern through the
posterior cul-de-sac the uterus was indurated and irregular. The uterine cavity
measured five inches. I could discover nothing in the interior of the womb by
exploration, though the whole cavity was explored as thoroughly as possible with the
sound. The history of the case, as well as the physical signs, seemed to point un-
mistakably either to a sub-peritoneal or interstitial fibroid.
For the purpose of curing the hemorrhage the curette was thoroughly applied
ECTOPIC PREGNANCY.
799
and brought away the usual débris found in fungoid endometritis. An application of
impure carbolic acid followed the use of the curette.
On the morning of April 28, she began to have peculiar bearing-down pains, but no
more severe than had often preceded the advent of the menstrual period. The pain
increased in severity until the first of May-thirty days after the use of the sound and
fifteen days after the curetting-when a somewhat distorted but well preserved fetus
of three months was expelled. The flooding was alarming, but by the timely arrival
of Dr. Long this was controlled, and the patient, under the influence of stimulants,
soon rallied from her syncope. The following four or five days she was very low
from a condition simulating shock, with much tenderness and pain in the region of
the left Fallopian tube; there was retention of urine and evidences of circumscribed
peritonitis. Under the influence of china, veratrum, and bryonia, with antiseptic
vaginal injections she rapidly improved, and, I believe regained her health perfectly.
A subsequent examination revealed no evidences of a double uterus and I cannot
but feel that this was a case of interstitial pregnancy which ruptured into the uterine
cavity.
The following case I present as one fairly illustrating the out-
come of ruptured extra-uterine pregnancy cysts if not inter-
fered with. The older literature abounds with numerous illus-
trations of the kind,
CASE LXXXIX.—“ Extra-uterine Pregnancy. Rupture. Death.—Mrs. M., mar-
ried, aged twenty-nine years, has had two living children; no miscarriages. She called
at my office February 6, 1884, complaining of dull pain in the right iliac region, back,
and rectum. There seemed to be a tendency to hysteria. She had had only a slight
flow at her last menstrual period, and was afraid she might be pregnant. Great
difficulty attended a vaginal examination, the mucus membrane being hyperesthetic.
The uterus was in its normal position. On its right side a round, soft body could be
felt, apparently of about the size of a walnut. Conjoined manipulation was rendered
impossible by the rigidity of the abdominal muscles. The patient had not had
connection with her husband since the completion of her last menstrual period. I
did not think she was pregnant, and considered her case one of chronic oöphoritis.
I was called again on the night of the 24th of February. After having been up most
of the day, the patient was taken with very severe neuralgic-like pains referred to
the region of the heart, and suffered from globus hystericus. It was learned from
her attendant that the symptoms developed while she was having some dispute with
her husband.
"The following week I attended her husband for alcoholism, and at that time Mrs.
M. was not complaining much, but worried a good deal about her husband, and had
had one or two hysterical attacks, with pain in the abdomen and rectum. On March
7th, she had another attack similar to the first, and from that time the attacks
became more frequent, some pain over the abdomen and in the rectum existing in the
intervals. The patient was confined to her bed most of the time. On one or two
occasions there was some nausea and vomiting, which I attributed to morphin. I
had now gained the confidence of the patient, and learned that she was troubled a
great 'deal, mentally, on account of domestic difficulties, and that the acute attacks
were always preceded by mental strain and excitement. At no time was there an
800
A TEXT-BOOK OF GYNECOLOGY.
increase of temperature. It was almost impossible to make a satisfactory examina-
tion of the genital organs, which was attempted on several occasions. On the 16th
she had another severe attack, one of her children having had a fall in her presence.
She described the location of the pain as being " in front and back passages;" also
over the abdomen and heart. There was nausea, with pallor and coldness of the
extremities. A vaginal examination could not be made, but I thought I could feel
a tumor, by external palpation, situated directly over the symphysis pubis. The
patient soon felt quite well again, and I left the house with my mind fully made up
to call Dr. George T. Harris in consultation the next day, give ether, and make a
thorough examination; but, finding the patient feeling well the next morning, and
being busy, I neglected to do as I intended. The patient passed a good night, and
was feeling well. Shortly afterward she called for the chamber, had some trouble in
passing her water, immediately followed by cries of distress and ‘Go for the doctor;
I am dying.' When I arrived I found her in a condition of collapse, with hardly
perceptible radial pulse, pale and exsanguinated. I at once suspected internal
hemorrhage, ordered external heat, gave hypodermic injections of brandy, ether, etc.,
and sent for Dr. Harris, who confirmed my fears of hemorrhage, and, from the
history, suspected extra-uterine gestation with rupture of the sac. The patient
gradually sank, and died at 3 P. M."—American Journal of Obstetrics, Vol. xviii,
p. 406.
CHAPTER LI.
INJURIES RESULTING FROM CHILDBIRTH.
LACERATIONS OF THE CERVIX UTERI.
History and General Considerations.-Lacerations of the
cervix are produced in nearly all instances by parturition. Sir
James Y. Simpson first called attention to the frequency of the
accident, and, later, Dr. Gardner, in his work on "Sterility,"
described somewhat in detail cervical lacerations and their
results. Dr. Gardner's work was published in 1856. Five
years later Professor Roser of Marburg drew attention to
ectropium of the cervix, especially dwelling upon the condition
as a cause of cervical ulceration. (Thomas.) He, however, like
Simpson and Gardner, did not appreciate the full importance of
the subject and its frequent association with lacerations. The
true significance of cervical lacerations was first recognized by
Dr. T. A. Emmet, who published his first paper upon the sub-
ject in 1869. This paper was unquestionably one of the most
important contributions ever made to the literature of gyne-
cology. Nevertheless, it was not until the publication of his
second paper, five years later, that its full importance was
appreciated. Since 1874 trachelorrhaphy, by which name the
operation for the closure of cervical rents is known, has
steadily grown in favor, though, like most innovations in medi-
cine, it has met with bitter opposition.
Not a few men have undertaken to build up a special uterine
pathology based upon cervical lacerations. As a result many
cervices have been operated upon which were better unmolested.
Dr. Emmet called attention to the various symptoms liable to
arise from the deposition of cicatricial tissue within the cervix,
and from the resulting ectropium, not the least important of
which being certain reflex neuroses. He, however, never
claimed that trachelorrhaphy is a "cure-all." Indeed, he has been
51
801
802
A TEXT-BOOK OF GYNECOLOGY.
most earnest in his efforts to impress upon the profession the fact
that operative cases must be selected with care and discrimination.
Notwithstanding his protests a certain class of men do not look
beyond the cervix for the origin of reflex phenomena. If a
cervical rent, no matter how slight, is found, further inves-
tigation ceases. Trachelorrhaphy is advised and performed, but
the promised relief does not follow, because the operation was
not indicated. It is not strange that indiscriminate work of this
kind should have induced the more conservative specialists to
call a halt. Fortunately, the operation has now reached its
proper level, and the indications for it are pretty clearly defined.
As a result it is performed by men of experience much less often
than formerly. When it is indicated, however, there are few
gynecological procedures more beneficent, and the profession
owes to Dr. Emmet unstinted gratitude for his labors in this
direction.
There
Frequency. The accident is of frequent occurrence.
are few women who have given birth to children at term whose
cervices are not more or less torn. As a general rule the rents
heal spontaneously, though some trace of them is usually left
behind. It is evident, therefore, that if all women having cervical
lacerations were operated upon, nearly every woman who has
given birth to a child would have to subject herself to the sur-
geon's knife. Clearly defined lacerations are met with only in
about thirty-three per cent. of parous women.
Etiology.—Under this head it will be necessary to consider
only those causes connected with parturition. One of the most
prominent of these is early rupture of the membranes, fol-
lowed by uterine pains sufficiently strong to force the head
through the undilated canal; the cervix not being sufficiently
dilated, and more or less hard and unyielding, a tear is almost
inevitable. An abortion as early as the third or fourth month
may give rise to such an accident, for, in early abortion, the
cervical tissues have not undergone marked changes and the
unyielding cervix is very liable to give way.
Cervical hyperplasia and endometritis, by their degenerative
influence, predispose to lacerations, especially if associated with
cystic disease.

LACERATIONS OF THE CERVIX UTERI.
803
Unquestionably the unskilful use of obstetric instruments is
responsible for cervical injuries in many instances. Yet, as in
perineal lacerations, the accident is oftener due to the tardy ap-
plication of the obstetric forceps than to its skilful and timely
use. However, cervical tears of the most serious character will
occur in the hands of the best obstetricians; it is, therefore, un-
just to censure the attending physician, as is often done, when
the injury is discovered by another. It occurs oftener at the
birth of the first child than at subsequent labors.
Varieties. These are:-
1. Lateral; uni- and bi-lateral (Figs. 70, 72, and 183);
FIG. 183.
FIG. 184.
BILATERAL LACERATION; UNEQUAL DIVISION MULTIPLE INCOMPLETE LACER-
OF THE CERVIX. (Skene.)
ATION. (Skene.)
2. Multiple or stellate (Figs. 68 and 184);
3. Antero-posterior, the posterior lip being the most frequent
site;
4. Incomplete. Here the solution of continuity is limited to
the mucous membrane and muscular wall of the cervix,
and does not extend to the mucous membrane of the
vagina.
Lateral lacerations are oftener located on the left side of the
cervix, probably because of the greater frequency of the left
occipito-presentation.
804
A TEXT-BOOK OF GYNECOLOGY.
Pathology. Cervical lacerations are so intimately connected
with subinvolution, endometritis (cervical and corporeal), areo-
lar hyperplasia, cellulitis, inflammation of the uterine append-
ages, etc., as to make it impossible to discuss their pathology
without frequently referring to these complicating lesions.
After the production of a laceration the wound may heal
spontaneously without in any way interfering with the involu-
tion of the uterus. If, however, the healing process is interfered
with because of septic or other influences, nature may make an
effort to close the rent by the deposition of cicatricial tissue.
This interferes with the uterine circulation, keeps the organ con-
stantly congested, arrests involution, and, in due time, gives rise
to fungoid endometritis. The tubes, ovaries, and broad ligaments
likewise participate in this congestion. The uterus, as a result of
the increased weight, frequently becomes displaced. There is be-
sides more or less squeezing of the terminal nerves by the cicatri-
cial plug, and as a consequence pain in the pelvis, thighs, and in-
deed in any part of the body may be produced. Emmet insists
that general anemia of a most profound character may result
indirectly from the cicatricial deposit.
If the rent is not filled in by this unnatural tissue the os re-
mains gaping and the whole cervical mucous membrane is more
or less exposed. It is consequently subjected to constant fric-
tion against the vagina, which gives rise to congestion, hyper-
plasia, and cystic or papillary degeneration. The epithelium is
destroyed by the resulting friction, and the underlying surface is
left raw and exposed, which constitutes an erosion. When the
hyperemia and hyperplasia involve the fundus of the uterus,
fungoid endometritis, with menorrhagia or metrorrhagia, re-
sults. If the rent is a lateral one, and has extended to the base
of the corresponding broad ligament, cellulitis of that ligament
is of frequent occurrence. This is due primarily to the absorp-
tion of septic matter through the rent, but it is perpetuated in a
subacute or chronic form by the resulting cicatricial tissue,
which interferes with the uterine and pelvic circulation.
It is necessary in studying the pathology of the accident to
refer to the possibility of malignant degeneration following in
its train. Emmet, Breisky, and others have especially empha-
LACERATIONS OF THE CERVIX UTERI.
805
sized the importance of cervical lacerations and injuries as caus-
ative factors in the production of epithelioma. It seems to me
not unreasonable to believe that cystic and papillary degenera-
tion, which so frequently result, the presence of lowly organ-
ized cicatricial tissue, and the constant friction due to the
ectropium, must necessarily favor malignant degeneration. At
any rate, epithelioma occurs much oftener in women who have
borne children than in nulliparæ.
Symptoms. These are most variable in intensity and char-
acter. The average woman will go through life with a cervical
laceration without suffering the least inconvenience from it.
Even when the pathological changes referred to have taken
place the symptoms are not necessarily distressing. The type
of temperament asserts itself here as in all gynecological affec-
tions. In one patient a slight laceration, with comparatively
insignificant complicating lesions, will produce the most intense
distress. In another an extensive laceration with erosion, ever-
sion, subinvolution, and hyperplasia, will create little if any
general disturbance. Usually, however, the endometritis, metri-
tis, subinvolution, and other complicating factors, give rise to
more or less local and general distress. Menstrual irregularities,
particularly menorrhagia and dysmenorrhea, are common symp-
toms. There is likewise more or less leucorrhea due to the en-
dometritis.
The most common seat of pain is the sacro-lumbar region.
Ovarian tenderness is frequently a marked symptom also. In
short, any of the phenomena studied under the head of the
various lesions enumerated as complicating factors may occur.
As time goes on malnutrition due to disturbance of the gastro-
intestinal tract, with consequent anemia, often becomes marked.
The reflex symptoms are most variable. Many of these have
been studied in the chapters devoted to the hystero-neuroses, to
which the reader is referred. Pain in the head and lower limbs,
infra-costal and infra-mammary neuralgia, profuse salivation,
hysterical joints, supra-orbital neuralgia-these and reflex phe-
nomena without number may, and often do, result from cervical
lacerations.
Upon digital examination the changed condition of the cervix.
806
A TEXT-BOOK OF GYNECOLOGY.
will be noted. If there is eversion the external os will be gaping,
and often the finger can be passed almost to the internal os. If
hyperplasia exists the tissues will feel hard and resisting. There
is increased sensitiveness at the angles of the rent where the de-
posit of cicatricial tissue is greatest. The cervix loses its
normal shape, the degree of distortion depending upon the
extent and character of the laceration. In cases of erosion
there will be seen through the speculum a raw, vascular surface,
which is sometimes partially concealed by the two lips of the
cervix. Occasionally the external os is but little larger than
normal, yet if the sound is passed 'through it into the cervical
canal the latter may be found greatly distorted. This is the so-
called "circular laceration" described by Emmet. It is easily
overlooked by the inexperienced examiner, because of the ab-
sence of eversion. The erosion may be entirely wanting, even
in the worst cases. I have many times found it absent in cer-
vices markedly enlarged by the deposition of cicatricial tissue
and hyperplasia. If the cervix is not indurated by hyperplasia,
and the amount of cicatricial tissue in the angles of the rent is
not great, the eroded surface may be entirely rolled in by tem-
porarily coaptating the lips with two tenacula.
Differential Diagnosis.—It is sometimes difficult to differen-
tiate simple erosion in nulliparæ from laceration. Care must,
therefore, be observed to guard the reputation of virgins where
such a condition exists (v. p. 435). It is impossible in nulli-
paræ to reinvert the lips of the cervix as can ordinarily be done
when laceration is responsible for the eversion. In cases where
papillary and cystic degeneration are marked the condition may
be mistaken for epithelioma (v. p. 436). Here the microscope.
must be the final test. Should there be much hyperplasia the
disease may be confounded with scirrhous cancer (v. p. 451).
Prognosis.-Eliminating the possibility of malignant degen-
eration, the prognosis, as regards life, is always favorable. Cer-
vical lacerations alone never kill, and, as we have seen, may give
rise to no inconvenience whatever. It is the complicating lesions
which must be considered in determining the prognosis. The
presence of the laceration is often first made known by some
undue exposure, unusual strain upon the nervous system, or the
LACERATIONS OF THE CERVIX UTERI.
807
onset of pelvic inflammation. In chronic pelvic inflammation
and uterine congestion the presence of the cicatricial plug per-
petuates the difficulty, and in order to cure these affections this
must be removed. So, too, in cervical and corporeal endome-
tritis, especially if eversion and erosion are marked. Much
relief, and even a temporary cure of the more distressing symp-
toms, may be brought about by proper palliative treatment. But
until the parts are restored to their normal condition by a suitable
operation the patient will usually relapse into her former state of
ill health after the treatment is discontinued. Clearly, then, the
significance of cervical lacerations depends rather upon the symp-
toms produced than upon the extent of the tears. This fact
must be borne in mind in considering the prognosis.
Immediate improvement, except in the neuroses, is not the
rule. This fact must be impressed upon the patient. The
operation will place her in a condition so that gradual improve-
ment will continue until she is perfectly restored to health. This
may require from three months to a year, depending upon the
existing lesions as well as upon the general symptoms which
such lesions have induced.
Treatment.—The palliative treatment should be directed to
any of the various complicating lesions, which have been enu-
merated, that may exist. Cervical catarrh and hyperplasia, sub-
involution, cystic and papillary degeneration, periuterine inflam-
mation, etc., can all be greatly benefited by the various measures
which are recommended for these conditions when they present
themselves as pathological entities. In all, the intelligent use of
the hot douche is invaluable. It should be used for its thermic
properties; hence, in very large quantities and very hot. The
application of the compound tincture of iodin to the cervix and
vaginal fornices, alternating with applications of impure carbolic
acid to the cervix alone, will do much good when the hyper-
plasia is marked. In cases of cystic and papillary degeneration
local scarification will hasten the cure. The vaginal tampon, made
of cotton-wool and properly medicated, will not only support the
parts, but by the pressure produced will promote the absorption
of any existing inflammatory exudates. In the event of con-
traction of the utero-sacral ligaments this should be overcome
808
A TEXT-BOOK OF GYNECOLOGY.
by intelligently applied pelvic massage. If there is relaxation
of the vagina, with cystocele or rectocele, the saturated solution
of alum may be advantageously used in connection with the
boro-glycerid tampon. This treatment, repeated twice or three
times a week, and persisted in from one to three months, will
ordinarily afford the greatest relief; indeed, in the slighter forms
of laceration this may be all that is necessary. In the worst
cases, however, the only way to bring about a permanent cure
is to resort to trachelorrhaphy. If the perineum and pelvic floor
are injured, these should be repaired at the same sitting.
Indications for Trachelorrhaphy.-When called for, there
is no operation more satisfactory than is trachelorrhaphy. The
cases which, in my hands, have been most benefited by it are
of two classes: subinvolution, with menorrhagia due to fungoid
endometritis; and hyperplasia of the cervix with a large amount
of cicatricial tissue. If reflex and nervous symptoms are par-
ticularly marked this is an additional indication for the opera-
tion even though the laceration is not extensive. Should dysmen-
orrhea and menorrhagia attend the laceration it is necessary,
ordinarily, to combine with trachelorrhaphy divulsion and cu-
retting. Not more than ten per cent. of all cervical lacerations
require an operation.
Operation. The patient is prepared, as for any operation
within the vagina, by having the bladder and bowels previously
emptied. A copious, hot, antiseptic douche is administered just
before she is placed upon the operating table; this must be hot
in order to obtain its hemostatic effects, at least two gallons of
water being injected. General anesthesia is advisable. The posi-
tion of the patient will depend upon the predilection of the oper-
ator. Formerly I used almost altogether the Sims posture.
More recently I have been using the Fritsch speculum, and with
the patient in the lithotomy posture the parts can be kept con-
stantly irrigated without wetting her. In order to expedite the
operation there should be four assistants-one to give the anes-
thetic, one on either side of the patient to support the knees,
hold the speculum, and make themselves generally useful during
the operation, and a fourth to look after the sponges. There
should be conveniently at hand two trays containing the follow-
LACERATIONS OF THE CERVIX UTERI.
809
ing instruments: Two tenacula; one Mundé's counter-pressure
hook; one Wood's wire twister (Fig. 95); one Sims's shield;
one pair of Emmet's cervical scissors; one pair of Skene's ten-
aculum forceps; one blunt-pointed uterine scalpel; one pair of
wire scissors; six trocar-pointed cervix needles, straight and
curved; four Wood's sponge holders (Fig. 94), containing sponges
of suitable shape; one uterine sound; perforated shot; one needle
holder; two coils of pure silver wire, Nos. 27 and 28; braided
silk and catgut.
The upper speculum is attached to an irrigating apparatus
containing a I: 5000 bichlorid solution. After the water is turned
on, the vagina is thoroughly washed with the fingers and with
a sponge held in a holder. The anterior lip of the cervix is
first seized between the points of Skene's volsella and trans-
fixed with a needle armed with a long braided silk. This is
next passed through the posterior lip, then drawn from the cer-
vical canal with a tenaculum, severed, and the two separate
loops tied. These "guy sutures" will give the operator perfect
control of the cervix. Their introduction requires but a
moment's time and the trouble is more than compensated for by the
advantage gained. An applicator dipped in impure carbolic acid
is now passed into the uterine cavity. If the nervous symptoms
are at all marked, or if there is a history of obstructive dysmen-
orrhea, the cervix is forcibly divulsed. If there is subinvolution
and menorrhagia, the sharp curette is next applied to the entire
endometrium, the débris wiped away, and a second application
of the impure carbolic acid made to the entire endometrium. This
practice I consider very important and undoubtedly the good
results obtained from trachelorrhaphy are enhanced by it.
With the patient upon her back the mucous membrane covering
the upper border of the posterior lip is caught in a tenaculum,
from which point it is removed to the corresponding left angle.
That of the anterior lip is dealt with in the same way, care
being taken to make the dissection extensive enough to remove
all of the cicatricial tissue, particularly at the angle of the rent.
The denudation of the right rent, in cases of bilateral tears,
is done in exactly the same way. Ordinarily, a strip of mucous
membrane a quarter of an inch wide, is left between the two

810
A TEXT-BOOK OF GYNECOLOGY.
vivified surfaces, as shown in Fig. 185. This is for the creation
of the new cervical canal. It is, however, of the greatest import-
ance that all of the cicatricial tissue and diseased glands should
be removed, even if the cervical canal must be invaded in order
to accomplish this. If I fear occlusion of the canal, I insert a
Cleveland glass plug (Fig. 60), but rarely is there danger of such
an accident if the sutures are properly inserted. I do not hesitate
to sever the circular artery if necessary to do so in order to reach
all of the cicatricial tissue. I once unwittingly penetrated the
folds of the broad ligament on each side, so that the two fingers
could be readily passed to the fundus uteri.* Under a stream of
bichlorid the requisite number of sutures was inserted, and before
the wound was closed the uterus was packed with iodoform
gauze for the purpose of controlling the free oozing of blood.
FIG. 185.
AREA OF DENUDATION IN TRACHELORRHAPHY. (Thomas and Munde.)
The
gauze was removed on the second day and the patient made
an uninterrupted recovery. However, so extensive a dissection
as this is unnecessary and not advised, but the danger attend-
ing injury to the circular artery has, I believe, been greatly
exaggerated.
For the removal of the cicatricial tissue I use almost altogether
the scissors shown in Fig. 186. By picking up with a tenaculum
the hard deposits, which can be felt distinctly with the finger,
they are easily removed with the scissors. Some operators
prefer for this purpose the uterine scalpels shown in Figs. 84
and 187.
*North American Journal of Homeopathy, June, 1891.
LACERATIONS OF THE CERVIX UTERI.
811
After the diseased tissue has been removed and the denuda-
tion completed, the parts are temporarily brought together by
the aid of the guy sutures to determine whether or not approx-
imation will be complete when the cervical sutures are introduced.
If the hemorrhage is profuse and comes from the circular
artery it can be controlled by passing deeply in the angle of
the wound a wire suture, and temporarily twisting it; or, the
spurting arteries can be secured by fine catgut ligatures. In
FIG. 186.

GETLE MANN
EMMET'S CERVICAL SCISSORS.
00
Sims's posture the upper row of sutures is first passed; in the
lithotomy posture it is a matter of indifference whether the right
or the left side of the wound is first closed. Care must be
taken to insert the sutures farthest from the operator, as high up
as possible in order to insure complete closure of the angles of
the wound. A cervical needle armed with a silk leader, in the
loop of which is placed a silver wire ten or twelve inches in
length, is seized with the needle holder and carried from without
FIG. 187.
G.TIEMANN & CO.
SCOTT'S UTERINE SCALPEL.
inward (Fig. 188). The number of sutures will vary from two
to six on each side, depending upon the extent of the tear. It
is not wise to place them too close together-ordinarily about
four to the inch. After a suture is passed, the ends are quickly
twisted together and given to an assistant, or placed under the
blade of the speculum. When all are passed, the operator
approximates the two sides of the wound, securing first the
sutures at the upper angles; this is done under a stream of
812
A TEXT-BOOK OF GYNECOLOGY.
bichlorid. Instead of twisting the sutures I now use perforated
shot for the purpose of securing them, because, if the twisted
wire is used, no matter how cautiously the ends are bent upon
themselves, it is liable to become buried and lost.* More than
once I have left twisted sutures behind. That this experience
is not peculiar to myself is proved by the writings of Mundé,
Emmet and others. After the sutures have all been secured
the vagina is again irrigated, wiped dry with sponges, and a
strip of iodoform gauze packed about the cervix with one end
left projecting from the ostium vaginæ. The gauze is introduced
to support the parts should the patient vomit from the effects
of the ether, and is removed as soon as the retching ceases.
FIG. 188.

T
INTRODUCTION OF SUTURES IN TRACHELORRHAPHY.
The after-treatment is very simple. The patient is placed in
bed, where she is kept for two weeks. The sutures are removed on
the tenth day, unless menstruation should make its appearance
at or about that time, or unless the perineum was restored at
the same sitting. She is permitted to urinate spontaneously
from the first, if able to do so. After urinating, a small sublimate
douche should be given. When the catheter is used the cleans-
ing douches are not called for.
* I have, during the last three months, been experimenting with the continuous
chromicized catgut suture for this purpose and, so far, have every reason to feel satis-
fied with the results obtained. This does away with the necessity of removing the
sutures, a consideration worthy of attention when the after-treatment is left in the
hands of one unaccustomed to removing them.
LACERATIONS OF THE CERVIX UTERI.
813
Lumbar pain from dragging upon the cervix is the most con-
stant symptom, and is usually made better by a few doses of
cimicifuga. If there is much tenderness or soreness over the
abdomen an ice-bag may be applied. Mundé recommends that
if there is retro-displacement a Hodge pessary be introduced
before the patient is removed from the operating table.
In order to remove the sutures the patient should be placed
before a good light and the parts exposed with a Sims speculum.
The first suture is caught in catch-forceps and severed with wire
scissors. This is repeated until all are removed. The higher
sutures can be located with the finger if they are not brought
into view by the speculum. The patient is permitted to get up
and about at the end of the second week, although if there is
marked subinvolution and pelvic congestion it is well to keep
her quiet longer than this. In the meantime the various meas-
ures having for their object the relief of existing complications
should be brought into requisition.
It cannot be said that trachelorrhaphy is entirely free from
danger, but the danger, if counter-indications do not exist, is
practically nil. The operation should not be done if acute in-
flammatory symptoms are present, or if the uterus is bound
down by adhesions. The danger from sepsis, if antiseptic pre-
cautions are resorted to, is very slight. A few deaths have re-
sulted from this and from pelvic inflammation; usually, how-
ever, serious pelvic inflammation is due either to uncleanliness
or to the fact that the counter-indications have not been care-
fully observed.
If the operation is properly performed the parts rarely, if ever,
fail to unite. When imperfect union takes place it can be attri-
buted, in most instances, either to excessive suture tension, to
sepsis, or to the depressed state of the general health.
Should hypertrophic elongation of the cervix complicate the
laceration the redundant tissue must be amputated. In doing
this care must be observed not to injure the bladder, rectum, or
pouch of Douglas (Figs. 117 and 191). The hypertrophy may
be limited to the vaginal portion, or it may implicate the supra-
vaginal portion and body of the uterus. When met with in
virgins, it is probably due to inflammation. The diagnosis
814
A TEXT-BOOK OF GYNECOLOGY.
I
is easily made by digital and conjoined examination.
prefer Simon's method of amputation. This is done by ex-
cising a wedge-shaped mass from the two lips, after which the
vaginal and cervical mucous membranes of either lip are
stitched together. Hegar removes the tissues by a circular am-
putation, and then brings together the vaginal and cervical
mucous membranes by a circular row of interrupted sutures.
In conclusion, it is necessary to allude to the probability of the
recurrence of the laceration should the patient again become
pregnant. The statistics of Wells show that a relaceration
occurs only in about twenty per cent. of all cases in which the
condition was noted after labor (Thomas and Mundé). It is
not probable that, unless conception occurs very soon after the
operation, the patient is any more liable to sustain a subse-
quent laceration than are nulliparæ.
CHAPTER LII.
INJURIES RESULTING FROM CHILDBIRTH.
(Continued.)
LACERATIONS AND INJURIES OF THE PERINEUM AND PElvic
FLOOR.
General Considerations and Anatomy.-There is no sub-
ject connected with gynecology more important than the one
under consideration. The frequency of these injuries, the dis-
tressing symptoms resulting from them, and the numerous
methods which have been devised, especially during the last ten
years, for their correction, make them, I think, of unusual
interest.*
The almost countless operative procedures, having for their
object the restoration of the perineum and pelvic floor, are the
outcome of numerous and widely differing theories put forth
by specialists and anatomists regarding the function of the
structures involved. The student is earnestly advised to study
carefully, before considering in detail the symptoms and treat-
ment of these injuries, the chapter devoted to the anatomy of
the pelvic organs. It is absolutely essential for him to com-
prehend the functions of the several structures of the pelvic
floor if he expects successfully to contend with the accidents
and injuries following in the train of parturition.
The pelvic floor, considered as a whole, is made up of mus-
cular and connective tissues which are so interlaced as to form a
firm and resisting diaphragm. These extend from the pubic
rami and ischia to the coccyx and sacro-sciatic ligaments, thus
closing the pelvic outlet (v. Figs. 4, 5, and 7). The pelvic floor is
pierced in the female by the vagina and the rectum. The anus
and lower extremity of the rectum are separated from the lower
extremity of the vagina by a triangular body known as the
* In the treatment of this subject I have borrowed liberally from the admirable
chapter by Dr. Howard A. Kelly in the "American System of Gynecology," Vol. II.
815
816
A TEXT-BOOK OF GYNECOLOGY.
perineum (Fig. 2). The importance of the perineal body as a sup-
porting structure is variously estimated. Thus, Kelly maintains
that its efficiency is inversely proportionate to its depth-very
deep perineums being weak and shallow, short ones strong. If
the perineum is considered as a separate part of the pelvic floor,
this view is unquestionably correct. If, on the other hand, we
look upon it as intimately connected with the pelvic floor by the
combination of muscle, fascia, vessels, nerves, fat, and areolar
tissue, its importance as a supporting structure will be neither
under-estimated nor unduly exaggerated. Being intimately
blended with these structures, it helps to sustain the posterior
vaginal wall and the anterior rectal wall, thus preventing their
prolapse, at the same time furnishing a support upon which the
anterior vaginal wall and bladder rest. Again, it directs the
contents of the rectum during defecation backward, thus pre-
venting the rectum from being forced into the vagina in the
form of a rectocele, as it also prevents a cystocele by the support
given to the bladder.
The levatores ani, which, together with their fascial coverings,
are by all odds the most important structures of the pelvic floor,
extend transversely across the pelvis at the upper portion of the
median line of the perineum. These muscles, together with the
transversus perinei and infra-vaginal portion of the triangular
ligament, can be felt by carefully palpating the posterior vaginal
wall just behind the hymen. They appear to the examiner as
a band or sling of fibers, which is sufficiently under the control
of the patient so that by it the vaginal orifice can be contracted or
relaxed. The fibers of the levatores ani hug in their embrace both
rectum and vagina, as is shown in Fig. 189. If these fibers are
separated from their lateral attachments to the rectum, the pelvic
floor is weakened and the vaginal outlet relaxed. The rectum
will, as it were, fall away from the vagina, so that the space
occupied by the perineal body is increased in its antero-posterior
diameter, providing the fourchette has not been torn. It is this
sort of a deep perineum which is weak, and which undoubtedly
has given rise to the too sweeping assertion that all deep peri-
neums are weak, whereas shallow, short ones are strong. If
the fibers of the levator ani are neither separated nor relaxed the
INJURIES OF PERINEUM AND PELVIC FLOOR.
817
functional activity of the pelvic floor, as a whole, is preserved,
whether the perineum be deep or shallow.
While, then, it is true that very deep perineums may be weak,
they are weak not because of the large quantity of areolar tissue
in them, but rather because the muscles and fasciæ are separated
from their median attachments.
As the presenting part of the fetus impinges upon the pelvic
floor during parturition, it forces the fibers downward and rolls
them outward and forward from under the pubic arch. The pel-
vic floor, in common with the entire parturient canal, is softened
by the changes incident to gestation, and, as the head descends
and recedes with each succeeding pain, the muscular fibers are
gradually stretched and dilated until, in normal cases, the head
is delivered without injury to the mother (Fig. 9). If there exist
a disproportion between the size of the parturient canal and the
FIG. 189.

DIAGRAM OF VAGINAL OUTLET, SHOWING RELATIONS OF THE LEVATOR, Rec-
tum, and VAGINA. (Kelly.)
fetus which has to pass through it, or if the pelvic floor is not
thoroughly relaxed before the fetus is expelled, injuries are
almost inevitable.
Forms of Injury.—Injuries to the pelvic floor resulting from
childbirth may be divided into two classes: :-
1. Visible tears, varying from a slight rent of the fourchette
to a laceration extending into the rectum.
2. Invisible or subcutaneous tears. Here the muscular fibers
and fasciæ are either lacerated or over-stretched. This condition
permits of great relaxation of the outlet, the injury being fre-
quently unrecognized because of the fact that the injury is con-
cealed by the mucous membrane.
A slight rent involving only the mucous membrane at the
fourchette is of frequent occurrence, especially in primiparæ,
52
818
A TEXT-BOOK OF GYNECOLOGY.
and, except as it furnishes an avenue for the entrance of germs,
is of little consequence. If it does not extend beyond the
sphincter the pelvic floor remains unweakened. When the recto-
vaginal septum is involved it may extend as far up the vaginal
canal as the cervix; usually it is confined to the lower inch of
the septum. Central perforation of the perineum is a rare injury,
though it occasionally occurs. It is the result of faulty posi-
tion of the presenting part, or of deformity of the pelvis which
drags the head backward instead of forcing it forward under the
pubic arch.
FIG. 190.
A

C
0
نا



A. Relation of levator, rectum, and vagina (diagrammatic). B. Same, showing deep
tear separating levator fibers from rectum in right sulcus. C. Same, showing
relaxation of outlet, separation on both sides. D. Same, showing tear into rec-
tum; levator fibers not injured. (Kelly.)
Invisible or concealed tears often extend up one or both vagi-
nal sulci, beginning at the posterior columna rugarum (Fig. 190).
One sulcus is usually more extensively involved than the
other, the separation even extending as high as the cervix. The
perineum may or may not be involved. These lateral injuries
correspond to the axis of the vagina and, extending in the direc-
tion of least resistance, separate the rectum from the levator ani
muscle. The rectum itself is left uninjured. In those injuries
extending through the recto-vaginal septum the muscular fibers
of the pelvic floor are ordinarily not separated. (Fig. 190, D.)
INJURIES OF PERINEUM AND PELVIC FLOOR.
819
Causes.-The various causes tending to produce laceration
and relaxation of the pelvic floor are:-
Occipito-posterior presentation and malpresentations in
general;
Excessive uterine contractions;
Narrow and too acute pubic arch;
Weakening of the perineum from syphilis ;
Excessive rigidity, especially in elderly primiparæ;
Obstetric operations, particularly forceps delivery.
The use of the obstetric forceps oftener produces superficial
injuries than concealed. Even in the hands of the most skilled
obstetrician, tears more or less extensive in character, will every
now and then result from its application. Nevertheless the
concealed injuries are oftener due to long continued distention
of the pelvic floor by the presenting part of the fetus than to
the intelligent use of instruments.
Spontaneous Reparation.-Nature, ever conservative, en-
deavors in her own way to repair injuries resulting from child-
birth. Thus, in relaxation from over-stretching of the fibers,
the outlet is more or less completely closed by the levator fibers
next beyond those which are injured. A constant spasmodic
effort, when the patient is not at rest, is made by these fibers,
though the contraction usually is insufficient to replace the
natural support. In visible tears not extending into the rectum
complete union will often occur if the parts are kept clean and
in apposition. Usually, however, such union is not possible
without surgical interference. If the parts do not heal in this
way, granulations are thrown out and scar tissue is created at
the site of the tear which often gives rise to distressing reflex
disturbances. This, in a measure, serves as a substitute for
the original tissue, the cicatricial mass affording a point of at-
tachment for the muscular fibers which are
perineum.
a part of the
In tears involving the recto-vaginal septum Nature is also able
to do much to remedy the accident. If the rent extends into the
anal border of the sphincter muscle only, subsequent cicatrization
will prevent extensive separation. If the septum is involved higher
up, the sphincter tends to contract at a point within the rent and
820
A TEXT-BOOK OF GYNECOLOGY.
more or less control of the bowel is preserved. However, after
a certain point is reached the sphincter no longer works concen-
trically and the rectum is so separated as to destroy all retaining
power.
Results of Relaxation and Laceration of the Pelvic Floor.
-Immediately after labor, it is impossible to recognize mere re-
laxation. After the patient is up and about she will complain
of indefinite bearing down pains and a feeling of insufficent
support at the vaginal outlet. As time goes on this distress
becomes more and more marked. The symptoms are particu-
larly aggravated by being on the feet, especially if the patient is
compelled to lift and do manual labor. In due time there is often
developed prolapse of the vagina with cystocele, rectocele, and
even enterocele.
Uterine congestion and the various forms of displacement,
especially prolapse, are not infrequently associated with relaxa-
tion and laceration. In complete laceration there is inconti-
nence of feces and gas.
The formation of a cystocele in these instances is due to the
intimate attachment of the bladder to the anterior vaginal wall.
The bladder loses the support afforded by the pelvic floor and
perineum which causes it to descend in the form of a pouch into
the vagina. At first this is small, but as time goes on it increases
in size until the tumor becomes sufficiently large to protrude
from the labia. Because of the inability to completely empty
the bladder, cystitis, dysuria, etc., result. The nature of the
tumor can readily be determined by passing a sound into the
bladder or by placing the patient in the genu-pectoral posture.
A rectocele or recto-vaginal hernia is produced by the same
causes which, acting in front, give rise to cystocele. As the
rectum pouches into the vagina, it becomes filled with fecal
matter, which is evacuated with difficulty. This gives rise to
tenesmus, hemorrhoids, obstinate constipation, and even serious
inflammation. The tumor varies in size from a simple protru-
sion to one as large as an orange. The diagnosis is readily
made by rectal exploration.
Enterocele or entero-vaginal hernia, is caused by the descent of

INJURIES OF PERINEUM AND PELVIC FLOOR.
821
a portion of the small intestines in such a way as to encroach upon
the vaginal canal. It is oftener located posteriorly. The intestines
in Douglas's pouch may gradually stretch this serous prolonga-
tion, which, pushing before it the posterior wall of the vagina,
may present at the vulva the form of a tumor. This condition is
FIG. 191.
4596
A vertical section of the female viscera showing hypertrophic elongation of the cer-
vix uteri with eversion of the vagina and descent of Douglas's pouch to the level
of the anus. The peritoneal surface of the body of the uterus is covered with
fibrous membranes, the result of peritonitis, and in its anterior wall are three small
myomatous tumors. (Museum R. C. S. Photographed by the Author.)
sometimes associated with hypertrophic elongation of the cervix
(Fig. 191). The symptoms of enterocele are usually not dis-
tressing. The diagnosis is made by rectal exploration and by the
tympanitic character of the sound elicited upon percussion. It
822
A TEXT-BOOK OF GYNECOLOGY.
is important to bear in mind the possibility of enterocele if the
vaginal tumor is first discovered during labor. Strangulation at
this time is not impossible and if the condition is mistaken for
other forms of vaginal tumors, serious consequences might result
from an incision. In all cases of doubt, capillary puncture and
aspiration are wise precautions to observe before thrusting a knife
into the tumor.
In cases of relaxation inspection will show that even though
the perineum is actually deeper than normal the ostium vaginæ
is not properly closed. The anal cleft, instead of presenting as
a sharp, deep furrow, is flat and shallow, and the anus drops
backward instead of being drawn up under the pubic arch. As
the finger is carried into the vagina the distinct transverse ridge
of fibers, extending from one pubic ramus to the other, cannot
be felt. The only resistance met with upon pushing the poste-
rior vaginal wall backward is the large open muscular loop which
rises low down on the pubic ramus, and passes around the rec-
tum and vagina just in front of the coccyx. If the patient is upon
her back, and the perineum is retracted with a finger in either
vaginal sulcus, the anterior and posterior vaginal walls will roll
out; in cystocele and rectocele the pouching is very marked.
Or, if she be placed in Sims's posture, the ostium is not
normally closed, but is sufficiently gaping to permit of the
entrance of air. If the finger be now carried into the vaginal
sulci the line of separation can be distinctly felt. In the erect
posture the intra-abdominal pressure tends to force the pelvic
contents from the weak outlet. There is usually more or less
descent of the uterus connected with relaxation.
TREATMENT.
This resolves itself into—
(1) Palliative;
(2) Surgical.
Palliative Treatment. The palliative treatment consists of
those measures having for their object the relief of pelvic con-
gestion and the temporary support of the uterus and vaginal
walls-the hot douche, the glycerin tampon, and a properly
fitted pessary, should there be uterine or vaginal displacement.
INJURIES OF PERINEUM AND PELVIC FLOOR.
823
Elderly women, especially, often decline to submit to operative
interference, and it is possible to keep them fairly comfortable by
the various palliative measures recommended in Chapter X.
Surgical Treatment-Primary Operation.-Recent superficial
tears should be repaired at once. This will not only make a
secondary operation unnecessary, but it closes one, and a very
important avenue for the reception of septic matter. If the tear
is a simple one, and does not extend into the sphincter, its closure
is not in the least difficult, and any physician capable of assum-
ing the responsibilities of an accoucheur ought to be able to
repair it.
The patient should be placed across the bed with her hips
projecting over its sides. After washing away the clots and
débris with a 1:4000 bichlorid solution, the surfaces of the wound,
if at all irregular, are trimmed with scissors so as to make coap-
tation perfect when they are brought together. I prefer silver
wire for suture material. This is threaded into an ordinary
straight perineal needle, which is carried through the tissues by
means of a needle holder. From one to four sutures will be
necessary, according to the extent of the tear. The first two
sutures are buried in the recto-vaginal septum, and are entirely
concealed. The third and fourth, if used, are introduced in such
a way as to make their appearance within the vagina. If, how
ever, the tear is more extensive and involves the posterior vagi-
nal wall, sutures must be passed within the vagina so as
to approximate the torn surfaces. The sutures are finally
secured by twisting or by perforated shot, care being taken not
to cause too great tension. The external sutures are entered
about a quarter of an inch from the margin of the wound and
are made to reappear at the corresponding point on the opposite
skin surface. After the sutures are secured the knees are tied
together. The sutures are left in from seven to ten days. If
the parts are kept scrupulously clean, union will result in nearly
every instance. The patient is allowed to urinate spontaneously,
if she can do so, after which a 1 : 5000 bichlorid douche is given.
If she cannot urinate spontaneously the catheter must be used.
If the tear extends through the sphincter, the technique of the
operation for its immediate closure will have to be modified.

824
A TEXT-BOOK OF GYNECOLOGY.
Failures are here much more common than is the case in deal-
ing with superficial injuries. The failure may be due to wound
infection from fecal and lochial contamination; or to a bruised
condition of the tissues which favors sloughing.
it
If the rent does not extend too far up the recto-vaginal septum,
may be closed by passing the sutures according to the method
FIG. 192.
6
5-
5
4
4
3
2
1
COMPLETE LACERATION. DENUDATION AND DISPOSITION OF THE SUTURES.
(Emmet.)
shown in Fig. 192. It is best, however, when the tear extends
any distance into the septum, to pass a sufficient number of in-
terrupted sutures from the vaginal and rectal sides of the wound
to coaptate the surfaces nicely. Silver wire may be used for
the vaginal surface, and silk or chromicized catgut for the rectal
surface. These should be introduced about four to the inch.
INJURIES OF PERINEUM AND PELVIC FLOOR.
825
In the after treatment of complete tears great care is necessary
to prevent hardened fecal matter from stretching the parts during
defecation.
Secondary Operation. By this is meant an operation upon
the perineum and pelvic floor after the parts have cicatrized-
from two months to several years following the injury. All gran-
ulations and inflammation at the site of the injury have disap-
peared, and in order to restore the parts to their normal condition,
raw surfaces must be created, either by denudation or by flap-
splitting.
There are certain general measures which should be attended
to previously to any of the secondary operations upon the peri-
neum and pelvic floor. It is not wise, especially in complete
lacerations, to operate while the patient's health is greatly de-
preciated. Unless the indications for immediate reparation are
imperative, sufficient time should be taken to build up the general
system. In incomplete lacerations, the bowels should be thor-
oughly emptied by a cathartic twenty-four hours before the
operation and the lower bowel washed out by an enema two or
three hours before the patient is placed upon the operating table.
She should be instructed to make a final effort to evacuate the
bowels just previously to taking the anesthetic. Unless this last
precaution be taken, water will be left behind which, together
with the liquid contents of the lower bowel, will be expelled
during the operation, much to the annoyance of the surgeon.
When the recto-vaginal septum is involved, a longer time should
be taken in order to insure complete emptying of the intestinal
canal of all fecal and scybalous matter. A cathartic should be
given every day for at least three days previously to the time
set for the operation. The patient should, during this time, live
almost entirely upon liquid food. The parts should be kept
clean by antiseptic vaginal douches. For the enemata a boracic
acid solution should be used.
General anesthesia is advisable in nearly all cases. Unless
ether is counter-indicated because of some kidney or lung
lesion, it is preferable to chloroform owing to its greater safety.
In superficial rents, and particularly if the patient is not very
nervous, it is entirely possible to operate with but little pain
826
A TEXT-BOOK OF GYNECOLOGY.
under the hypodermic use of cocaine. Occasionally, patients are
met with who dread the anesthetic more than the operation. As
a rule, however, general anesthesia is advisable. Immediately
before the anesthetic is administered, a large hot vaginal bichlorid
douche is given, for its hemostatic as well as its antiseptic
effect.
FIG. 193.

*G TIE MANN=CO.
SIMS'S SHARP CURVED SCISSORS.
A large number of instruments is unnecessary. There should
be a pair of scissors curved on the flat (Fig. 193); a pair of an-
gular scissors (Fig. 160); two tenacula; two or three straight
round perineal needles (ordinary darning needles about two
inches long); two short curved needles; three or four catch-
forceps; a needle holder; silk or chromicized catgut; Fritsch's
FIG. 194.

G.TIEMANN &COR
יון
EMMET'S Double Curved Scissors.
or Sims's speculum; an irrigator; and a Kelly pad. The
crutch is, in my opinion, entirely unnecessary. Emmet's right
and left scissors curved on the flat are a convenience rather than
a necessity. (Fig. 194.)
Assistants.-Four assistants are necessary: two to support
the patient's limbs, hold the speculum and assist the operator in
various ways; one to aid with the instruments and sponges; and
one to give the anesthetic.

INJURIES OF PERINEUM AND PELVIC FLOOR.
827
Position of the Patient.-For all operations upon the peri-
neum and posterior vaginal wall the lithotomy posture is the
preferable one. In anterior colporrhaphy it will be necessary
to utilize the Sims or semi-prone posture in order to expose
the anterior vaginal wall.
FIG. 195.
FIRST STEP; DENUDATION BEGUN. (Skene).
The character of the operation will depend upon the extent
and nature of the injury.
RESTORATION OF THE PERINEUM ONLY.
Simple Denudation and Coaptation.-The assistants, one on
each side of the patient, support the limbs which are flexed upon
the abdomen, and with the unoccupied hands separate the labia

828
A TEXT-BOOK OF GYNECOLOGY.
so as fully to expose the parts. The operator hooks a tenaculum
into the muco-cutaneous surface of the left side at a point cor-
responding to the upper margin of the rent (this is indicated by
the scar tissue), and with a pair of curved or straight scissors
dissects up a strip of mucous membrane at its junction with the
skin surface and extending from this point to a corresponding
point on the opposite side (Fig. 195). The tenaculum is now dis-
carded and the strip of mucous membrane is held in the left hand.
With a pair of scissors curved in the opposite direction another
FIG. 196.
SURFACE DENUDED AND SUTURES IN POSITION. (Thomas.)
strip is removed from right to left. This is repeated until the
denudation is carried to the required height; usually an area
corresponding to that shown in Fig. 196 is denuded.
The sutures (silkworm gut or silver wire) are now passed.
I prefer for needles ordinary straight darning needles. They
are inexpensive, readily penetrate the tissues, and, because of
their shape, give rise to no hemorrhage. The lower suture is
first introduced a short distance from the skin surface and made
INJURIES OF PERINEUM AND PELVIC floor.
829
to reappear at a corresponding point on the opposite side of the
wound. From three to five sutures, depending on the size of
the denuded area, are ordinarily required. All except the last
are entirely concealed and should be passed with the finger in
the rectum as a guide so that the rectum may not be penetrated.
In inserting the last suture it is better, instead of introducing
it as is shown in the illustration, to pass it through the tissues
at the upper angle of the wound on the left side, then carry it
through the apex of the vaginal mucous membrane close to the
point of denudation, causing it to reappear on the skin surface
of the opposite side of the wound. When the sutures are
tightened this will elevate the vaginal mucous membrane to the
highest point of the wound, thus preventing the formation of a
sulcus just above the newly-made perineum, which, by the re-
tention of secretions, may interfere with union. During the
entire operation constant irrigation is kept up with a 1:5000
bichlorid solution. It is rarely if ever necessary to do any-
thing more than to temporarily compress spurting arteries in
order to control the hemorrhage.
The lower suture is first temporarily secured by two or three
turns with the hands, and each succeeding suture from below
upward is dealt with in the same way. After the parts are
nicely coaptated each suture is seized in succession about two
inches from the wound, in the blades of a wire twister (Fig.
95), and quickly twisted. There is danger of creating too much
tension in doing this. The tension should be only great enough
to hold the parts in nice coaptation, making due allowance in all
cases for more or less swelling. It is a good plan, after the
twisting, to shoulder the sutures with two tenacula. There
should be but little pain after perineal operations, and when it
occurs it is due to excessive suture tension. After the wires are
twisted the ends are cut about two inches from the skin surface.
The several ends are then twisted into one coil and protected
either with absorbent cotton or a piece of rubber tubing. The
limbs are brought together before the sutures are twisted.
When the operation is completed the parts are carefully cleansed,
wiped dry (the vagina being cleansed with a sponge held in a
holder), sprinkled with iodoform, and a strip of iodoform gauze

830
A TEXT-BOOK OF GYNECOLOGY.
packed into the vagina. An antiseptic pad should also pro-
tect the newly-made perineum. The patient is then placed in
bed with her limbs tied together.
The buried animal suture may be utilized for coaptating the
denuded surfaces instead of the outside sutures. If used, great
care must be observed to prevent suture infection. Catgut
should be chromicized in order to prevent too rapid absorption.
The suture should not be permitted to touch any part of the
FIG. 197.
FLAP-SPLITTING OPERATION FOR INCOMPLETE LACERATION OF THE PERINEUM.
(LINES OF INCISION.) (Munde.)
patient or the table during the operation. A long catgut is
threaded in a suitable needle, passed at the apex of the wound
and tied. It is then reintroduced, grasping only a portion of the
denuded surface, and interlooped. The sutures are passed
about four to the inch until the lower angle or skin surface of
the wound is reached. The catgut is pulled taut and held by
an assistant as it is each time drawn through the tissues. It is
next carried backward, including a still wider strip of tissue,

INJURIES OF PERINEUM AND PELVIC FLOOR.
831
until finally the wound is completely closed, the last row
approximating the mucous and skin surfaces. The chief
advantage of the animal suture is that it does not require
removal. To prove successful, however, the strictest antiseptic
precautions must be observed in its use.
Flap-splitting Operation.-This operation, now so popular
with the larger number of specialists, was reintroduced by Law-
son Tait and has received the imprimatur of his name. It is admir-
FIG. 198.
FLAP-SPLITTING OPERATION FOR COMPLETE LACERATION OF THE PERINEUM.
(LINES OF INCISION.) (Munde.)
ably adapted to those cases of simple laceration uncomplicated
with pelvic relaxation, and complete lacerations involving the
inferior extremity of the recto-vaginal septum. It possesses the
great advantage of being quickly and easily performed. In order
to prevent confusion I will describe under the present head the
operation for both complete and incomplete tears.
The patient is placed in the lithotomy posture, the index
finger of the left hand is passed into the rectum for a guide, and
832
A TEXT-BOOK OF GYNECOLOGY.
with a pair of angular scissors (Fig. 160) introduced into the
left side of the recto-vaginal septum, the tissues are split from
left to right (Fig. 197). Tait makes this median incision from a
quarter of an inch to half an inch deep. If the laceration is an
incomplete one the incision is carried up on either side to a
point corresponding to the upper angle of the perineal rent.
the recto-vaginal septum is involved in the tear it is also ex-
tended downward and backward on both sides of the transverse
incision to a point just beyond the edges of the sphincter ani
muscle (Fig. 198).
If
The upper and lower flaps are now caught in two pair of catch-
forceps or two tenacula, the upper being drawn upward and the
lower drawn downward (Fig. 200). The sutures are passed from
left to right and from below upward by means of a needle with
fixed handle (Fig. 199), or, as I prefer, by straight, round darn-
FIG. 199.

G.TIEMANN & CO
PEASLEE'S PERINEAL NEEDLES.
ing needle. The latter makes a smaller wound and the bruising
of tissue is much less than when a regular perineal needle is
used. The sutures should be passed very close to the edge of
the wound (Lawson Tait even recommending that the skin sur-
face be left untouched). I agree with Mundé, however, that it
is better to include a small portion of the skin surface, for by
so doing coaptation is made more complete. After all of the
sutures have been introduced they are secured in the ordinary
way. The puckering of the posterior commissure, which inevi-
tably results, is closed by a continuous catgut suture. I shall
speak of my modification of this operation in dealing with re-
laxations of the pelvic floor.
This is a most ingenious, and, ordinarily, a most successful
operation. For complete tears I think that it is unexcelled. Its
superiority over the older method was most forcibly impressed
upon me by a case sent to me by Dr. Sutherland of South Bend,

INJURIES OF PERINEUM AND PELVIC FLOOR.
833
Ind. The recto-vaginal rent extended for at least two inches
above the lower border of the sphincter; the operation was done
six weeks after confinement, while the parts were yet subinvo-
luted and exceedingly vascular. The hemorrhage was most pro-
fuse, and it became necessary to tie a good many arteries with
FIG. 200.
FLAP-SPLITTING OPERATION FOR LACERATED PERINEUM. APPEARANCE OF
WOUND AND INTRODUCTION OF SUTURES FOR BOTH VARIETIES. (Munde.)
catgut which was evidently contaminated; at any rate, wound
infection from some cause ensued. Sloughing occurred, but not
until after the rectal and vaginal portions of the wound had
united. The sloughing gave rise to an excavation in shape not
unlike that shown in Fig. 200. This, in time, entirely filled in
by granulation, and the patient recovered with perfect control of
the sphincter.
53
834
A TEXT-BOOK OF GYNECOLOGY.
Other Methods of Closing Complete Tears.-Various other
operations, having for their object the reparation of complete
tears, are now and have been for many years in vogue. Of
these Hegar's, Hildebrandt's, Simon's, Baker Brown's, Emmet's,
Freund's, and Goodell's are best known. In the first four the
vivification is confined to the posterior vaginal wall and is
median; in the last three it is bilateral and is made in the
vaginal sulci. Of these various operations Emmet's is the most
popular in this country, although, in my opinion, infinitely more
difficult and unsatisfactory than the flap-splitting method. I
will, however, for the sake of completeness, briefly describe it.
Emmet's Operation. The area of vivification is well shown in
Fig. 192. It represents a triangle on either side of the lacerated
perineum. At the apex of the tear the two triangles are con-
nected in the median line, the denudation being carried some
three centimeters above the point of laceration. It will be seen
by studying the figure that the median denudation represents
the body of a butterfly and the lateral portions its wings. The
parts are closed with silver wire of median size and the introduc-
tion of the sutures is of great importance. The point of the
needle armed with the first suture is introduced one centimeter
and a half behind and outside the anus, on the left side. This is
carried through the inferior part of the recto-vaginal septum
and is made to appear on the right side of the anus at a corres-
ponding point. The sutures must be guided by the left index
finger in the rectum. Four or five sutures, one above the other,
and all concealed within the vagina, are passed in this way.
They are secured as in incomplete lacerations. If perfect coap-
tation of either the mucous or the skin surface is not secured
superficial catgut sutures may be introduced. The first suture
is by all odds the most important one and must catch the ends
of the broken sphincter muscle in such a way as to bring them
into perfect coaptation when the suture is secured. The vivi-
fication is carried only to the border of the rectal mucous
membrane.
If the rent extends more than two inches upward it may
be closed by continuous or interrupted vaginal and rectal
sutures. For the rectal suture chromicized catgut should be
INJURIES OF PERINEUM AND PELVIC FLOOR.
835
used; for the vaginal suture wire, silk, silkworm gut, or chro-
micized catgut, as the operator may select.
In all operations for complete tears the operator must keep in
mind the three objects to be attained, viz., the restoration of the
perineal body; the closure of the rectal opening; and, finally,
the restoration of the sphincter ani muscle. Of these three
objects the last is by all odds the most important; unless com-
plete union of the two ends of the severed sphincter muscle is
obtained, failure, either partial or complete, is inevitable.
FIG. 201.

EMMET
SIMON
GISCHOFF
HEGAR
GRITSCH
SUPERIMPOSED DIAGRAMS OF FRITSCH'S, HEGAR'S, BISCHOFF'S, SIMON'S AND
EMMET'S OPERATIONS.
OPERATIONS FOR RELAXATION WITH RECTOCELE AND
CYSTOCELE.
The various operations which have been devised to overcome
relaxation of the pelvic floor, with rectocele, are shown diagram-
matically in Fig. 201.
These, embracing as they do various degrees and shapes of de-
nudation, have all been devised for the purpose of picking up the
relaxed tissues underneath the vaginal mucous membrane which

836
A TEXT-BOOK OF GYNECOLOGY.
are responsible for the rectocele and for the deficient pelvic sup-
port. They all, if properly performed, narrow the posterior
vaginal wall. The breadth of denudation in all is greatest just
within the vaginal outlet, which brings together at this point the
lower border of the triangular ligament and the relaxed leva-
tores ani muscles. Of the median operations I will describe
Hegar's, as being the one oftener performed.
Hegar's Operation.-The patient is placed upon her back
with the thighs flexed upon the abdomen. The field of opera-
tion is fully exposed by a Fritsch speculum passed underneath
the pubes when the cervix is caught by its posterior lip
in a stout tenaculum or volsella and drawn downward (Fig.
202). Two tenacula are fixed at the highest point of the peri-
FIG. 202.
HEGAR'S OPERATION.
neal tear, one on either side, and retracted. This procedure
will nicely expose the area to be denuded. With a scalpel two
lateral incisions are made, beginning at the crest of the rectocele,
which is usually just below the cervix, and extending down the
sides to a point corresponding to the tenacula. The apex of the
denuded area is caught in a third tenaculum and dissected from
above downward. After a flap large enough to be held by the
fingers is dissected up, the tenaculum is discarded and the tri-
angular section is removed to the skin surface. This is then
incised either with the scissors or the scalpel. Bleeding surfaces
are temporarily caught in snap forceps. Constant irrigation is
kept up during the operation.

INJURIES OF PERINEUM AND PELVIC FLOOR.
837
The wound is closed by continuous catgut, or by inter-
rupted sutures. If the continuous buried suture is used it is
carried from above downward in successive rows until the parts
are perfectly approximated. It is sometimes best to introduce
one or two rows of buried catgut, bringing the mucous mem-
brane together with interrupted silver wire sutures. After the
vaginal surface is approximated the perineal wound is closed by
silver wire sutures passed from without.
Emmet's Operation.-In Emmet's operation the denudation
is "posterior median in front and bilateral on either side of the
FIG. 203.
DENUDATION IN THE EMMET OPERATION. SUTURES PASSED. (Kelly.)
columna," extending into one or both sulci for a variable distance.
In Fig. 190, the manner in which the fibers connecting the
levator ani and rectum are separated, is shown diagrammatically.
The object of Emmet's operation is to utilize the vaginal sulci
in such a way as more thoroughly to catch these fibers and bring
them together. The operation is performed as follows:-
An elliptical surface in each lateral vaginal furrow is de-
nuded (Fig. 203).
203). This is accomplished by separating the
labia and catching the crest of the rectocele in a tenaculum.
Two other tenacula are hooked into the tissues near the car-
838
A TEXT-BOOK OF GYNECOLOGY.
uncles on either side. If, now, the tenaculum which is hooked
into the rectocele is pulled to the left, a triangle is formed which
extends from this tenaculum to the tenaculum on the right side.
A strip of tissue is removed between these two tenacula varying
in width according to the extent of the denudation required.
The crest of the rectocele is next drawn to the opposite side and a
strip of tissue extending between this tenaculum and the one on
the left side removed in the same way. This will leave an area
of undenuded tissue between the crest of the rectocele and
the skin surface, which is to be removed with a pair of curved
scissors. As a result there will be left a denuded surface ex-
tending into the sulci on either side. If the relaxation is
greater in one sulcus than in the other, the denudation may be
carried higher on that side.
The manner of passing the sutures, devised by Dr. Emmet,
is all-important, and is also shown in Fig. 203. Either silver
wire, silkworm gut, or chromicized catgut may be used. In
order to expedite the operation I use the continuous catgut
suture, and cannot see but that the results are quite as good as
when interrupted silver wire or silkworm gut is used. Begin-
ning at the apices of the triangles they are passed transversely,
the first not extending deeper than the mucous membrane.
The subsequent stitches enter the vaginal mucous membrane
close to the margin of the denudation and are passed deeply
toward the operator, brought out at the bottom of the sulcus
lower down than the point of entrance, reëntered near the same
point and made to appear on the lateral vaginal wall close
to the margin of denudation. Care should, of course, be taken
not to injure the rectum. If interrupted sutures are used they
may be secured as soon as passed. Usually from three to eight
inside sutures will be sufficient to complete the operation. There
will be left a small perineal surface unapproximated after the
internal sutures are secured (Fig. 204). This is closed by two
or three sutures passed from the outside just within the posterior
commissure, not upon the skin surface.
The Author's Operation for Relaxation and Rectocele.
With or Without Laceration of the Perineal Body.—Tait's
method of flap-splitting for incomplete tears is, as I have en-

INJURIES OF PERINEUM AND PELVIC FLOOR.
839
deavored to show, a most ingenious one when the perineal body
alone is to be built up. I have, however, been led to modify
somewhat the technique given by Tait, Mundé, and others. As
ordinarily performed there is left at the site of the newly created
commissure a superfluous amount of tissue which is of no use
FIG. 204.
INTRODUCTION OF SUTURES IN EMMET'S OPERATION. THE VAGINAL SUTURES
ARE TIED. (Thomas and Munde.)
whatever for supporting purposes: the vaginal mucous mem-
brane, being drawn downward without the ostium vaginæ, is
liable to become irritated upon walking and during sexual con-
gress. To overcome this I remove a small triangular portion
of tissue at the upper angle of the wound and bring the oppos-
840
A TEXT-BOOK OF GYNECOLOGY.
ing surfaces together with a chromicized catgut suture which
is further utilized for the more perfect coaptation of the skin
surfaces between the external wire sutures. This restores the
fourchette to a virginal state as nearly as can be done by any
operative procedure.
If relaxation of the pelvic floor with rectocele is associated
with the perineal rent, the flap-splitting operation, as ordinarily
performed, will overcome neither the relaxation nor the rec-
tocele. If the recto-vaginal septum is split high enough to
bring together the separated underlying muscles and fascia and
the wound is closed by external sutures alone, there will exist
a degree of tension which will probably defeat the chief end of
the operation; besides, the diaphragmatic pelvic muscles and
fasciæ, instead of being restored to their normal relationship, are,
when the external sutures are tightened, pursed in a most un-
natural way underneath the pubic arch. Of course this opera-
tion can be supplemented by any of the forms of posterior
colporrhaphy which have been described, and in this way the
rectocele and relaxation overcome. But when colporrhaphy is
performed according to the method of Emmet, Hegar, Fritsch
and others, it is a somewhat tedious operation, involves an un-
necessary loss of tissue, and leaves behind avenues for septic
infection. To overcome these several objections I have devised
a method which, I believe, will more perfectly restore a relaxed
pelvic floor than any yet devised. It is, indeed, an extended flap-
splitting operation and was suggested to me because of the con-
servative nature and extreme simplicity of the latter method of
restoring the perineum. It is a combination of Lawson Tait's
and Doleris's flap-splitting methods, of Schroeder's method of
detaching the mucous membrane, and of Emmet's method of
suturing. I proceed as follows:-
The patient is placed in the usual lithotomy posture with an
assistant on either side who retract the labia with the fingers.
The index finger of the left hand is carried into the rectum to
serve as a guide. The character of the transverse incision will
depend upon the extent of the perineal rent. If the perineal
body is not torn and the condition is one of simple relaxation,
it is made with a pair of angular scissors close to the fourchette,

INJURIES OF PERINEUM AND PELVIC FLOOR.
841
and is carried below the mucous membrane only (Fig. 205).
At the muco-cutaneous surface this need not be more than half
an inch in width, the separation being carried laterally as far as
is necessary underneath the mucous membrane. If the perineal
body is to be restored it is made exactly as in Fig. 197, with
corresponding lateral incisions, except that the lateral incisions
should not extend quite as high as is recommended in the orig-
inal Tait operation. In either event the dissection, instead of
FIG. 205.
a
FIRST STEP OF THE AUTHOR'S SUBCUTANEOUS OPERATION.
a, b, Line of Incision.
being extended into the recto-vaginal septum for half an inch
only, is carried as high as the crest of the rectocele, even though
this requires a separation two inches or more in depth. If the
degree of relaxation is marked, it is extended laterally into
one or both sulci; indeed, the dissection may be limited to one
or both sulci, as in Emmet's operation, instead of making it
posterior median. The separation may be done with a pair
of blunt-pointed scissors, with the handle of a scalpel, or with
842
A TEXT-BOOK OF GYNECOLOGY.
the finger. I think it best to use the finger only, for the
tissues are easily separated, and by tearing them apart the hem-
orrhage is reduced to a minimum; there is also much less dan-
ger of penetrating either the rectum or the vagina, than when a
cutting instrument is used. This step of the operation is facili-
tated by catching the vaginal mucous membrane in a pair of
forceps and drawing it upward; it can be completed in a
minute's time. A stream of hot bichlorid should be kept playing
upon the parts during the entire operation.
A chromicized catgut suture twenty-four inches in length is
threaded in a half curved needle three-quarters of an inch long
and is passed through the vaginal mucous membrane, just above
the apex of the wound, and tied at its middle. From this point
it is carried down the sulcus of the left side as a continuous
suture to the skin surface. This is handed to an assistant, the
free end threaded into a curved needle and carried down the right
sulcus in the same way. These two sutures are made to traverse
the lower vaginal orifice transversely, meeting at the median
line, along which, on either side, they are carried to the
apex
of
the wound and tied. The three outer rows of sutures include
a triangular area of mucous membrane, the base of which cor-
responds to the vaginal outlet and the apex to the crest of the
rectocele. The two median rows traverse this triangle from the
center of the base to its apex. The sutures are interlooped,
passed about four to the inch, and in the sulci are directed for-
ward according to the method of Emmet (Fig. 203) except, of
course, that they cannot be made to appear at the bottom of the
wound. The tissues are, however, so lax that there is but
little difficulty in turning the needle so as to imitate the direction
of the Emmet suture. The median rows are passed only deep
enough to catch the underlying tissues. If the skin and mucous
membrane are not nicely coaptated by the transverse row they
should be brought together with a continuous catgut suture.*
* Latterly I have substituted interrupted silver wire sutures for the catgut. These
are introduced through the vagina in such a way that the needle penetrates the rectal
flap a little to the left of the median line, when it is carried around the left sulcus,
is buried in the rectal flap and made to reappear at the upper and outer border of
the right sulcus, when it again penetrates the vaginal flap near the point of entrance.
INJURIES OF PERINEUM AND PELVIC FLOOR.
843
If the perineal body is torn through and requires building up,
a triangular section is removed from the vaginal flap as in the
modified Tait operation. This insures the removal of all cica-
tricial tissue. The transverse sutures are passed above the
apex of this section within the vagina, after which the wound is
closed with from three to five sutures passed from the skin surface.
This will result in a firm, solid perineum, the depth of which will
depend upon the extent of the lateral incisions. For perineal
sutures I prefer silver wire.
I claim for this submucous method of perineo-colporrhaphy the
following advantages:-
1. It is more simple and can be more quickly performed than
can any of the colporrhaphies which necessitate the denudation
of the vaginal mucous membrane, especially if the denudation is
made lateral.
2. It conserves all tissue, except when a small triangle of
mucous membrane is removed for the purpose of restoring the
perineal body.
3. By conserving the mucous membrane the pelvic floor is
greatly strengthened, while the rectocele is overcome perfectly.
4. The wound is entirely closed, except at the vaginal orifice,
so that the possibility of septic infection is reduced to a min-
imum.
Let it be remembered that this is essentially a submucous opera-
tion. The separated muscles and fasciæ are drawn together
underneath the mucous membrane, though the sutures are passed
through the vaginal canal. The mucous membrane becomes
firmly adhered to the underlying structures, which it holds to-
gether, after the parts are healed, as a broad strip of adhesive
plaster holds together the gaping edges of a skin wound. It
does not create within the vagina the redundant columns of
mucous membrane as would seem to be the case upon first
When the sutures thus introduced are tightened, the ends of the separated muscles
and fascia will be drawn together underneath the vaginal flap. This brings the
separated muscles and fascia together at the median line which is not the case when
the sulci alone are utilized. From one to three vaginal sutures will be required and
can be secured either by twisting or by perforated shot.

844
A TEXT-BOOK OF GYNECOLOGY.
thought. On the contrary, it restores the vagina to nearly a
virginal state, at the same time drawing the anus and the vaginal
outlet toward the pubic arch more effectually than does any
operation I have ever yet performed or seen performed.
Anterior Colporrhaphy or Elytrorrhaphy.-When prolapse
of the anterior vaginal wall, with cystocele, is at all marked it
FIG. 206.
STOLTZ'S OPERATION FOR CYSTOCELE. (Thomas and Munde).
will be necessary to perform an operation having for its object
the relief of the cystocele. Innumerable operations have been
devised for this particular purpose, all of which involve more or
less denudation and destruction of tissue. Thus Hegar denudes
a surface the shape of an ellipse, which is very blunt at the upper
extremity. Emmet recommends giving the denuded surface the
INJURIES OF PERINEUM AND PELVIC FLOOR.
845
+
form of a mason's trowel. Stoltz makes a circular denudation.
The fact is, the form of denudation is not in the least important.
It is necessary to incise freely the exuberant portion of the
vagina. Pozzi includes in the jaws of two or three forceps the
folds of mucosa to be removed, which extend about three centi_
meters from the orifice of the urethra to about two centimeters
from the cervix. The tissue seized is removed with a pair of
scissors, and after the forceps are detached the wound is brought
together either with the continuous suture in superimposed rows,
or with silver wire. Stoltz closes his circular denudation with a
suture armed with a needle at each end, which he passes as
shown in Fig. 206. This is a most satisfactory and expeditious
way of closing the wound. During the dissection Stoltz de-
presses the anterior vaginal wall with a sound in the bladder.
In urethral prolapse Skene makes an incision through the
vaginal mucous membrane on each side of the urethra, extend-
ing from half an inch within the vulva to an inch or more
upward and outward. The wound is closed with superimposed
rows of buried catgut sutures by which the tissues below the
vaginal wall are united to the fascia of the subpubic ligament.
This operation involves no destruction of tissue.
After-treatment of Colpo-perineorraphy.-The post-opera-
tive care of all plastic cases is very important, if union by first
intention is to be obtained. The patient is placed in bed with
her knees tied together. If she can urinate spontaneously she
is permitted to do so from the very first, after which a small
1 : 5000 bichlorid douche is administered. If she cannot urinate
spontaneously a catheter must be introduced every six hours; in
this event the cleansing douche is not called for. In those cases
involving the recto-vaginal septum the greatest possible care
must be observed in the management of the bowels. I think it
is better to keep them confined with small doses of opium for
the first four days. A cathartic is then given which is supple-
mented by an enema of glycerin in order to insure complete
liquefaction of the feces. During the evacuation of the bowels
the nurse should watch the patient carefully and if any scybal-
ous masses present at the anus, they should be dissolved by
permitting a stream of warm sterilized water to play upon them.
846
A TEXT-BOOK OF GYNECOLOGY.
In incomplete operations the bowels may be moved on the third
day by an enema of glycerin and water. Subsequent evacua-
tions are secured in the same way upon alternate days. If wire
sutures are used they are removed from the seventh to the tenth
day.
There should be no persistent rise of temperature following
perineorrhaphy or colporrhaphy if the case progresses normally.
A persistent elevation usually indicates suppuration which, in
the larger number of cases, is along the tract of some suture
which is twisted too tightly; or, if the buried suture has been
used, from wound infection. However, the temperature will
often temporarily rise a degree or a degree and a half soon
after the operation, but this quickly subsides and is purely reac-
tionary. Should it remain persistently elevated the wound
should be inspected, and if there is suppuration along the tract
of one or more of the sutures, these should be removed; or, if
swelling is excessive so that the pain is very great, the tension
should be relieved by untwisting the sutures.
Results. In incomplete colpoperineorrhaphy failure is rarely
if ever met with. If it does occur, it is due either to faulty op-
erative technique, to septic infection, or to improper after-
or.
treatment. In complete tears successes are not always met
with, even in the hands of the best operators. However, since
practising the flap-splitting method I have not met with a
failure.
Mortality.—A few cases are on record where death has re-
sulted from tetanus and septicemia. As a rule, these operations
are not dangerous and the few deaths which have been recorded
were due to causes which might have set up fatal complications
in any cutting operation. The operator should, nevertheless,
bear in mind that the perineal region is particularly rich in
lymphatics—hence the importance of strict antiseptic pre-
cautions.
A.
INDEX.
Abdomen, regions of, 95.
Abdominal pregnancy, 794.
Abscess, pelvic (v. Pelvic abscess),
480; of the vulvo-vaginal glands,
331.
Adenitis, 65.
Alexander's operation, 562.
Amenorrhea, 230; varieties, 230;
symptoms, 231, 232, 233; treat-
ment, 234; electricity in, 160.
Amputation of uterus for inversion,
582.
Anatomy of the female pelvic or-
gans, 30; development of the
ovum, 30; external genitals, 31;
muscles of the female perineum,
33; fascia of the pelvic floor, 35;
deeper fasciæ, 36; perineal sep-
tum, 38; pelvic floor dissected
from above, 39; fascial coverings
of muscles of pelvic floor, 41; peri-
toneum, 43; ligaments of uterus,
45, 47; peritoneal pouches,
49; pelvic cellular or connective
tissue, 50; uterus and annexa, 51;
Fallopian tubes, 53; ovaries, 54;
vagina, 54; bladder, urethra, and
rectum, 55; ureters, 56; blood-
vessels and lymphatics, 57.
Anesthesia as a hystero-neurosis,
198.
Angioleucitis, 65.
Angioma, urethral venous, 511.
Anomalies of secretion and excre-
tion, 204.
Anterior colporrhaphy, 844.
+
Anteversion and anteflexion, 547;
diagnosis, 547; treatment, 550;
pessaries in, 551.
Antisepsis in gynecology, 170; the
agents employed, 173; the opera-
tor and assistants, 173; the patient,
173; the operating-room, 175;
the operation, 175; disinfection of
instruments, 175; ligatures, 176;
sponges, 177; drainage tubes,
177; tamponnement of perito-
neum, 178; irrigation, 179; dress-
ings, 180; preparation of gauze,
180; after-treatment, 181; cathe-
terization, 181; care of drainage
tube, 182; in ordinary gyneco-
logical examinations, 182.
Aphonia, reflex, 208; during meno-
pause, 288.
Areolar hyperplasia, 442; general
considerations and pathology,
442; causation, 446; varieties,
448; symptoms, 449; physical
signs, 450; differentiation, 450;
prognosis, 451; treatment, 452;
therapeutics, 459.
Ascites, diagnosis of, from ovarian
cyst, 693.
Aspirator in diagnosis, 87.
Asthma, reflex, 206, 207.
Astringents and styptics, 147, 249.
Atresia of the vagina, 370; of the
vulva, 364.
Atrophy of the labia majora and
nymphæ, 321.
Auscultation, 115.
B.
Bandaging, tight, after parturition,
as a cause of disease, 24.
Barrenness (v. Sterility and impo-
tence), 306.
Bartholinian glands, abscess of, 331;
cysts of, 331.
Bichlorid of mercury as a germi-
cide, 173.
Bimanual examination, 101.
Bladder, anatomy of, 55; inflamma-
tion of, 492, 498; mucous mem-
brane cast off, 73; irritability of,
515; neoplasms of, 514; parasites
of, 515; stone in, 513.
Blennorrhagia, 378.
847
848
A TEXT-BOOK OF GYNECOLOGY.
Blood supply of pelvis, 57; volume
of, in menstruation, 292.
Borax in dysmenorrhea, 275.
Broad ligaments, cysts of, 669, 674.
Bulbs of the vestibule, rupture of,
334.
C.
Calcaria iodid in fibroma uteri, 624.
Calculus, vesical, 513.
Cannabis Ind. in uterine hemor-
rhage, 254.
Carcinoma of the body of the uterus,
637; pathology, 637; symptoms,
637; physical signs, 637; pro-
gress, 639; prognosis, 639; treat-
ment, 641.
Carcinoma of the cervix, 627; gene-
ral considerations and etiology,
627; varieties and pathology, 629;
symptoms, 631; physical signs,
632; differentiation, 633; progress
of the disease, 634; prognosis, 635 ;
cause of death, 636; palliative
treatment, 641; therapeutics, 645:
curative treatment, 646; vaginal
hysterectomy for, 647; Pratt's
operation for, 654; illustrative
cases, 657.
Carcinoma of ovary, 672, 676; of
uterus, 627; of vulva, 339.
Caruncles, urethral, 511.
Case, record, 58; taking, 58.
Catheter, use and care of, 181.
Catgut, care in using, 176; prepara-
tion of, 176.
Causes of gynecological diseases,
17; inherited feebleness of consti-
tution, 18; defects in or absence of
development, 19; acquired feeble-
ness of constitution, 19; deficient
air and exercise, 20; improper
dress, 20; exposure during men-
struation, 21; improper care dur-
ing and after parturition, 22; mari-
tal irregularities, 26; reflex func-
tional disturbance and nervous
disorders, 24; development of
new growths and malignant dis-
ease, 27; uterine displacements,
27; inflammatory, 28; accidental,
28.
Caustics, 148.
Cellular tissue, pelvic, 50.
Cellulitis and peritonitis (acute),
402; frequency and causes, 407 ;
pathology, 409; symptoms, 412;
physical signs, 415; complications,
416; differentiation, 417, 428;
course, duration, and sequelæ, 419;
prognosis, 420; treatment, 420;
therapeutics, 424.
Cervix, carcinoma of (v. Carcinoma
of the cervix), 627; erosions
of, 430; fibroid tumors of, 591;
granular and cystic degeneration
of, 430, 454; hypertrophic elonga-
tion of, 448, 573, 813, 821.
Cervix, lacerations of, 801; his-
tory and general considerations,
801; frequency, 802; etiology,
802; varieties, 803; pathology,
804, symptoms, 805; differentia-
tion, 806; prognosis, 806; treat-
ment, 807; indications for trache-
lorrhaphy, 808; trachelorrhaphy,
808.
Change of life (v. Menopause), 280.
Circulatory disturbance as a hystero-
neurosis, 201.
Climaxis, 280 (v. Menopause).
Climaxis, hystero-neuroses during,
187.
Clitoris, anatomy of, 31; atrophy of,
321; hypertrophy of, 321.
Cocculus in dysmenorrhea, 276.
Coccygodynia, 358; anatomy, 358;
causes, 358; pathology, 359; symp-
toms, 359; differential diagnosis,
360; treatment, 360; therapeutics,
361.
Coition, painful, 68, 317.
Coitus, causes interfering with, 310.
Colpocystotomy, 502.
Conception, prevention of, as a cause
of disease, 26.
Condylomata of the vulva, 338.
Congestion of the ovary, 763.
Congestive and inflammatory dys-
menorrhea, 261.
Conjoined manipulation, 101.
Constipation, 125; diet in, 126;
mechanical causes, 127; enemata
in, 127; therapeutics of, 128.
Constitution, acquired feebleness
of, 19; inherited feebleness of,
18.
Corporeal endometritis, 437.
Corrosive sublimate as a germicide,
173.
Cough, hysterical, 206.
INDEX.
849
Curette in uterine hemorrhage, 250,
255.
Cyst and abscess of vulvo-vaginal
glands, 331.
Cystic and allied diseases of the
uterine appendages, 663, 673,
683, 702; classification, 663;
symptoms, 673; course and termi-
nation, 678; contingencies, 678;
diagnosis, 683; differentiation,
686; diagnosis of small ovarian
tumors, 699; tapping for diagnosis,
700; ovariotomy, 702, 724; illus-
trative cases, 732.
Cystic oöphoro-salpingitis, 743.
Cystic polypi of the uterus, 619.
Cystitis, acute, 492; frequency, 492;
pathology, 493; etiology, 494;
symptoms, 495;, differentiation,
495; treatment, 496; therapeutics,
503.
Cystitis, chronic, 498; etiology,
498; symptoms, 499; treatment,
499; therapeutics, 503.
Cystocele, 820, 844.
Cysts, vaginal, 375; of Bartholinean
glands, 332; ovarian, 663.
D.
Defecation, painful, 67.
Degeneration, granular and cystic,
of the cervix, 429; fungoid, of the
endometrium, 212.
Dermatoses, 212.
Dermoid cysts of ovary, 666, 674.
Development, defects in or absence
of, 19.
Diagnosis of bodies expelled from
vagina, 73; physical, 77, 93,
105.
Diarrhea, during menopause, 289.
Diet in neurasthenia, 130.
Dilatation of the urethra, 509.
Dilators, uterine, 86.
Dipsomania, during menopause, 288.
Discharges, significance of, 70; path-
ology, 70; table of comparison,
71.
Disinfectants, 148.
Divulsion in dysmenorrhea, 268, 270;
during menopause, 287.
Double touch, 101.
Douche, vaginal, 138; indications
for, 139; method, 139; counter-in-
dications, 142; in uterine hemor-
rhage, 247.
Douglas', cul-de-sac, 49.
Drainage, in abdominal section,
716; Mikulicz's method, 178;
tubes, 177.
Dress, improper, 20.
Dysmenorrhea, 257; general con-
siderations, 257; varieties, 258;
symptoms and diagnosis, 259-
266; treatment, 267; electricity in,
162; therapeutics, 272; illustra-
tive cases, 277.
Dysmenorrheal membrane, 73.
Dyspareunia, 317.
Dysuria, from cellulitis, 414.
E..
Ectopic pregnancy, 769; definition,
769; varieties, 770; etiology, 772;
pathology, 774; symptoms, 776;
diagnosis, 783; prognosis, 785;
treatment, 786; electricity in, 789;
technique of laparotomy for, 791 ;
management of placenta, 792;
vaginal extraction, 794 ; illustrative
cases, 794.
Electricity in gynecology, 152; gal-
vanism, 153; faradism, 154;
Franklinism, 155, 158; appara-
tus, 155; galvanometer, 156; rheo-
stat and electrodes, 156; general
considerations, 157; electro-punc-
ture, 159; in amenorrhea, 160, 234;
in dysmenorrhea, 162, 267; in
subinvolution, 164; in superinvo-
lution and atrophy, 164; in ovar-
algia, 165, 766; in chronic ovaritis,
166, 754; in chronic pelvic inflam-
mation, 166, 754; in uterine dis-
placements, 167; in endometritis,
168, 455; schema, 169; antisepsis
in the use of, 183; in chronic
diseases of the uterine append-
ages, 754; in nervous prostration,
131, 134.
Elytrorrhaphy, 844.
Embryology, 30.
Emmet's operation for complete
tears of perineum, 834; for lacera-
tion of cervix, 808; for relaxation
of pelvic floor, 837.
Encapsulated ovarian cysts, 721.
Endocervicitis (v. Endometritis,
chronic cervical), 429.
54
850
A TEXT-BOOK OF GYNECOLOGY.
Endometritis, acute (v. Metritis and
endometritis), 399.
Endometritis, chronic cervical, 429;
definition, 429; anatomy, 430;
pathology, 430; etiology, 433;
symptoms, 434; physical signs,
435; differentiation, 436; prog-
nosis, 436; treatment, 452; thera-
peutics, 459; electricity in, 168.
Endometritis, chronic corporeal,
437; anatomy, 437; pathology,
437; causation, 438; symptoms,
439; physical signs, 441; differen-
tiation, 441; prognosis, 442; treat-
ment, 455; therapeutics, 459; illus-
trative cases, 457; electricity in,
168.
Endometrium, fungoid degeneration
of, 437.
Enteritis, membranous, 211.
Enterocele, 820.
Entero-vaginal fistula, 540.
Epilepsy, reflex, 217.
Episiorrhaphy, 535.
Epistaxis, vicarious, 305.
Epithelioma of cervix, 627; of vulva,
339.
Ergotin in fibroids, 590, 625.
Erosions of cervix, 430.
Eruptions of vulva, 325.
Erythema, in pelvic disease, 204.
Etiology of gynecological diseases,
17.
Eversion of cervical mucous mem-
brane, 435; digital of rectum, III.
Examination, antisepsis in, 182.
External organs of generation, dis-
eases of, 320, 342; deformities
of the vulva, 321; eruptions, 325;
vulvitis, 327; inflammation and
abscess of vulvo-vaginal glands,
331; pudendal hemorrhage and
hematocele, 334; pudendal hernia,
336; hydrocele, 337; edema of the
labia majora and nymphæ, 338;
neoplasms of the vulva, 338; dif-
ferentiating table, 341; pruritus
vulvæ, 342; hyperesthesia of the
vulva, 349.
Extra-uterine pregnancy (v. Ectopic
pregnancy), 769.
Exudations, pelvic, 410, 415.
F.
Fallopian tubes, anatomy of, 53;
diseases of, 737, 754.
Fasciæ, pelvic, 35, 36.
Fecal fistulæ, 537.
Fibro-cystic tumors of the uterus,
613; symptoms, 613; treatment,
614.
Fibroid tumors of the uterus, 583,
599; definition, 583; pathology,
583; varieties, 583; number, size,
and location, 584; structure, 585;
degenerative changes, 587; of
the cervix, 591; etiology, 591;
symptoms, 593; physical signs,
595; progress and termination,
597; prognosis, 597; palliative
treatment, 599; surgical treatment,
600; enucleation in submucous
fibroids, 601; oöphorectomy for,
603; laparotomy for, 603; man-
agement of pedicle, 605; compari-
son of extra and intraperitoneal
method, 609; myomectomy, 609;
vaginal hysterectomy for, 610;
removal of during pregnancy,
610; therapeutics, 624.
Fibrous polypi of the uterus, 615.
Fissure of the urethra, 510.
Fistulæ, fecal, 537; vesico-vaginal,
518; uretero-uterine, 533; uretero-
vaginal, 533; urethral, 534; recto-
labial, 540; entero-vesical, 541;
entero-vaginal, 540.
Fistulæ, recto-vaginal, 537; symp-
toms and diagnosis, 537; physical
signs, 538; prognosis, 538; treat-
ment, 538.
Fistulæ, urinary, 518; varieties,
518; pathology, 518; etiology,
519; symptoms, 520; physical
signs, 521; prognosis, 521; treat-
ment, 522; operation for, 523;
after-treatment, 529.
Flap-splitting operation, 533, 831.
Flexions of uterus, 547, 554.
Flow, retention of, 233.
Follicular degeneration of cervix,
429, 454.
Fossa navicularis, 32.
Fourchette, 32.
Franklinic current, application of,
158.
Fungoid degeneration of endome-
trium, 437.
G.
Galvanism, 153; in amenorrhea,
160; in dysmenorrhea, 162, 267;
INDEX.
851
in endometritis, 168, 454; in ova-
ralgia, 165, 766; in chronic ovaritis,
166, 754; in chronic pelvic in-
flammation, 166, 424; in sub-
involution, 164; in superinvolu-
tion, 164; in uterine fibroids, 600.
Galvanometer, 156.
Gastric neuroses, 209.
Gastro-hysterorrhaphy,563; results
and prognosis of, 564; illustrative
cases, 566; for prolapse of the
uterus, 575.
Gauze packing in abdominal sur-
gery, 178, 736; preparation of,
180.
General pathology of gynecological
diseases (v. Pathology, general,
of gynecological diseases), 117;
treatment of gynecological dis-
eases (v. Treatment, general, of
gynecological diseases), 124.
Genu-pectoral posture, 91.
Gestation, causes interfering with,
312; ectopic, 769.
Glandular disturbances, reflex, 214.
Gonococcus of Neisser, 74, 381.
Gonorrhea, 378; causing pelvic in-
flammation, 382, 739.
Graafian follicles, 54.
Granular degeneration of the cervix,
429, 454; vaginitis, 384.
Guaiacum in dysmenorrhea, 277,
278.
Gynecological dressings, 180; ex-
aminations, antisepsis in, 182.
H.
Heart, disturbances of from pelvic
diseases, 201.
Hegar's operation for rectocele, 836;
extra-peritoneal method of treat-
ing pedicle, 605.
Hematocele, extra-peritoneal, 472;
etiology, 472; pathology, 473;
symptoms, 474; treatment, 475;
therapeutics, 478.
Hematocele, intra-peritoneal, 463;
etiology, 463; sources of the
blood, 465; pathology, 466; symp-
toms, 468; progress of the disease,
469; signs of suppuration, 470 ;
diagnosis, 470; prognosis, 471;
treatment, 475; therapeutics, 478.
Hematocele, pelvic, 463; pudendal,
334.
Hematometra, 368.
Hematosalpinx, 743.
Hematuria, 515.
Hemorrhage, pudendal, 334.
Hemorrhagic discharge from genital
canal, 73.
Hemorrhoids, vicarious discharge
from, 304.
Hermaphrodism, 376.
Hernia, pudendal, 336; entero-vag-
inal, 820; recto-vaginál, 820.
Hydatids, 73.
Hydrastis Can. in uterine hemor-
rhage, 254; local use of, 145.
Hydrocele, 337.
Hydrosalpinx, 743.
Hymen, anatomy of, 32; double,
374.
Hymen, imperforate, 365; anat-
omy, 365; symptoms, 365; treat-
ment, 366.
Hymen, persistent, 369; treatment,
370.
Hyperemia, forms and sequelæ of,
120.
Hyperesthesia of the vulva, 349;
treatment, 350; therapeutics, 351.
Hyperesthesia as a hystero-neurosis,
192; of the internal os, 283, 287.
Hyperplasia, areolar, of the uterus,
442.
Hypertrophic elongation of the cer-
vix, 448, 573, 813, 821.
Hypogastric region, pain in, 61.
Hysterectomy for uterine inversion,
582; for uterine prolapse, 575; for
uterine cancer, 646.
Hysterical joint, 196; paroxysm, 223.
Hystero-neuroses, 184, 192, 209;
definition, 184; general considera-
tions, 185; forms of, 186; physio-
logical, 187; diagnosis, 189; prog-
nosis, 190; symptomatology, 192;
hyperesthesia, 192; anesthesia,
198; clonic and tonic spasms, 199;
paralyses, 200; circulatory distur-
bances, 201; anomalies of secre-
tion and excretion, 204; disorders
of respiration, 205; gastric neuro-
ses, 209; intestinal neuroses, 210;
disorders of the skin, 212; glandu-
lar disturbances, 214; disorders of
the nervous system, 216; epilepsy,
217; the hysterical paroxysm, 223;
therapeutics, 225.
Hystero-psychoses, 216.
852
A TEXT-BOOK OF GYNECOLOGY.
Hysterorrhaphy for retro-displace-
ments, 563.
I.
Imperforate hymen, 365.
Impotence and sterility, 306.
Improprieties of dress as a cause
of disease, 20.
Imprudence after parturition as a
cause of disease, 22.
Incision of the cervix in uterine
fibroids, 600.
Incision of the external os in cervi-
cal endometritis, 454.
Incomplete ovariotomy, 720.
Indigestion, 124.
Inflammatory diseases of uterine
appendages, 737, 754; general
considerations, 737; classification,
738; non-cystic oöphoro-salpingi- |
tis, 739; cystic oöphoro-salpingitis,
743; pathology, 750; progress and
termination, 752; prognosis, 752;
treatment, 754; salpingo-oöphor-
ectomy for, 755; illustrative cases,
758.
Inhaler, Junker's, 88.
Injuries due to parturition, 801, 815.
Insemination, causes preventing,
308.
Inspection, 110.
Instruments, care of in gynecologi-
cal examinations, 182.
Interstitial pregnancy, 798.
Intestinal neuroses, 210.
Intestines, prolapse of, 570, 820.
Intra ligamentous ovarian cysts, 721.
Intra-peritoneal pregnancy. 794.
Inversion of the uterus, 576; etiol-
ogy, 576; symptoms, 578; physical
signs, 579; termination, 580; treat-
ment, 580; manual reduction, 580;
reduction by taxis, 581; reduction
by gradual compression, 581; am-
putation for, 582.
Iodoform gauze for peritoneal tam-
ponnement, 178; preparation of,
180.
Irremovable ovarian cysts, 720.
Irritable bladder, 515; urethra, 513.
K.
Kidney, mucous membrane of pelvis
cast off, 73.
Kleptomania during menopause, 288.
Knot, Staffordshire, 715.
Kolpokleisis, 535.
L.
Labia, majora and minora, 31.
Labia majora, hypertrophy of, 321;
atrophy of, 321; phlegmonous
inflammation of 330; edema of,
338.
Lacerations of cervix (v. Cervix, lac-
erations of) 801.
Laparotomy for fibroids, 603.
Lead poisoning as a cause of menor-
rhagia, 240.
Leucorrhea (v. Discharges, signifi-
cance of), 70; vicarious, 302.
Levatores ani in relaxation of pelvic
floor, 816.
Ligament, vesico-uterine, 45-
Ligaments, broad, 47; cysts of, 669.
Ligaments, round, 47.
Ligaments, utero-sacral, 47 ;
con-
traction of as a cause of dysuria,
68, 414.
Lister's, Sir Joseph, clinic, 171.
Liver, reflex disturbances of, 214.
Local applications, 142; alum, 147;
belladonna 147; boracic acid, 148;
boro-glycerid, 143; calendula, 145;
carbolic acid, 146; caustics, 148;
chloral hydrate, 147; conium mac,
147; eucalyptus glob., 148; gly-
cerin, 143; hydrastis Can., 145;
iodin, 143; iodoform, 148; iron,
147; opium, 147; tannin, 147;
treatment of gynecological dis-
eases (v.Treatment, local, of gyne-
cological diseases), 138.
Local lesions which cause reflex
symptoms, 119.
Lower extremities, pain in, 65.
Lumbar pain, 59.
Lymphangitis and lymphadenitis,
65.
Lymphatics of pelvis, 57.
M.
Malformations of external genitalia,
331; of vagina, 363.
Mammæ, reflex disturbances of, 216.
Marital irregularities, 26.
Martin's operation for myomectomy,
609.
Massage in nervous prostration, 133.
Membranous dysmenorrhea, 265;
milfoil in, 277.
Menopause, 280; anatomical
changes, 281; symptoms, 281;
INDEX.
853
treatment, 284; therapeutics, 286;
illustrative cases, 287.
Menorrhagia and metrorrhagia (v.
Uterine hemorrhages), 238.
Menstrual blood, retention of, 233,
365.
Menstruation, exposure during, 21;
hystero-neuroses during, 187;
painful, 66.
Menstruation, physiology of, 226;
theories, 227; source of hemor-
rhage, 229; changes in endome-
trium, 229; volume of blood in,
292; vicarious, 290.
Mercury bichlorid as a germicide,
173.
Metritis and endometritis (acute),
399; anatomy, 399; causes, 399;
pathology, 400; symptoms, 400;
differentiation, 401; prognosis,
402; treatment, 420; therapeutics,
424.
Metritis, chronic (v. Areolar hyper-
plasia), 442.
Microscope in diagnosis, 74.
Micturition, painful, 67.
Moles, hydatidiform, 73, 75; fleshy,
74.
Mons Veneris, 31.
Morbid perspirations, 289.
Muciparous follicles in the vagina,
378.
Mucous discharge from genital
canal, 71.
Mucous membrane, cervical, anat-
omy of, 430; of the fundus, anat-
omy of, 437.
Mucous polypi of the uterus, 618.
Mundé's flanged speculum, 81.
Myo-fibromata of the uterus, 583.
Myomectomy, 609.
Narcotics, 147.
N.
Neoplasms of bladder, 514; of the
vulva, 338.
Nervous and blood supply of pelvis,
118.
Nervous prostration (neurasthenia),
129; symptoms of, 129; Weir
Mitchell's treatment of, 130; diet
in, 132; local treatment in, 134;
therapeutics of, 135.
Neuralgic dysmenorrhea, 259.
Neurasthenia (v. Nervous prostra-
tion) 129.
Neuroses, the, 121, 184, 192, 209.
New growths and malignant disease,
development of, 27.
Noegerrath on latent gonorrhea in
the female, 382, 739.
Non-cystic oöphoro-salpingitis, 739.
Nott's speculum, 79.
Nymphæ, atrophy of, 321; hyper-
trophy of, 321.
O.
Obstructive dysmenorrhea, 262; di-
vulsion in, 268.
Offensive discharges from genital
canal, 72.
Oophorectomy for diseases of ap-
pendages, 755; for uterine fibroids,
603.
Opium in carcinoma uteri, 643 ; local
use of, 147.
Ovaralgia, 766; electricity in, 165,
766.
Ovarian dysmenorrhea, 260; region,
pain in, 60.
Ovarian tumors (v. Cystic and allied
diseases of the uterine append-
ages), 663; adhesions, 681; carci-
nomatous, 672, 676; causes of
erroneous diagnosis, 685; con-
tents of simple and multiple cysts,
666; course and termination, 678;
curability of by internal medica-
tion, 678; dermoid or cutaneous
piliferous cysts, 666, 674; diag-
nosis, 683; differentiation, 686;
fibromatous, 671, 675; multiple
cysts, 665; inflammation of in-
terior of cyst, 680; obstruction of
the bowel, 681: papillomatous,
668, 669, 674; pedicle of, 672;
prognosis, 682; proliferous, 665;
rupture of ovarian cysts, 680;
sarcomatous, 672; simple cysts,
663; symptoms, 673; tapping for
diagnosis, 700; terminations, 681;
twisting of pedicle, 679.
Ovaries, anatomy of, 54; congestion
of, 763.
Ovaries, neuralgia of, 766; diag-
nosis, 766; symptoms, 766; treat-
ment, 766, 767.
Ovaries, prolapse of, 764; diagno-
sis, 765; symptoms, 764; treat-
ment, 765, 767.
Ovariotomy, 702; abdominal inci-
sion, 707; anesthetics, 707; ar-
854
A TEXT-BOOK OF GYNECOLOGY.
rangement of instruments, 705;
cleansing the peritoneum, 715;
closing abdominal wound, 718
clothing, 705; drainage, 716;
dressing the wound, 719; encap-
sulated cysts, 721; general prin-
ciples of abdominal section, 702 ;
illustrative cases, 732; incomplete
ovariotomy, 720; indications, 703;
intra-abdominal
manipulations,
711; management of adhesions,
713; preliminary details, 705;
table, 704; tapping the cyst, 711;
temperature of the room, 705;
treatment of pedicle, 713; after
treatment, 724; care of bowels,
726; care of drainage tube, 717;
diet, 725; nurse, 724; pain, 726;
position, 726; pulse and tempera-
ture, 727; septicemia and peri-
tonitis, 728; therapeutics, 731;
tympanites, 728.
Ovaritis, acute, 417; chronic (v. In-
flammatory diseases of uterine
appendages), 737; electricity in,
166.
Ovulation, causes interfering with,
312; and menstruation, connec-
tion between, 227.
Ovum, diagnosis of, 73.
P.
Pachysalpingitis, 738.
Pain, the significance of, 59; as re-
gards location, 59; as regards
function, 66; as regards posture,
68.
Palpation, abdominal, 93.
Papillary vaginitis, 384.
Paralysis, hysterical, 200.
Parametritis, 402.
Para-uterine cellulitis, 402.
Parovarium, 53; cysts of, 671, 675.
Parturition, improper care during,
22.
Pathology, general, of gynecological
diseases, 117; nervous and blood
supply of the pelvic organs, 118;
how distant organs are involved,
119; nature of local lesion caus-
ing reflex symptoms, 119; forms
of hyperemia, 120; the sequelæ
of hyperemia, 120; the neuroses,
121; how general symptoms are
induced by local disease, 121; how
local disease is induced by sys-
temic disturbance, 122; tempera-
ment and constitutional bias, 123.
Péan's extra-peritoneal method of
treating the pedicle, 606.
Pelvic abscess, 480; pathology,
481; symptoms, 482; differentia-
tion, 483; prognosis, 484; treat-
ment, 484; illustrative cases, 489.
Pelvic floor, 40; fascial coverings of,
41.
Pelvic hematocele (v. Hematocele,
pelvic), 463.
Pelvic pouches, 49; cellular tissue,
50; inflammation (acute), 402;
(chronic) electricity in, 166.
Percussion, 115.
Perineal septum (triangular liga-
ment), 38.
Perineorrhaphy, primary operation
(v. Perineum and pelvic floor, in-
juries of), 815.
Perineum, muscles of, 33.
Perineum and pelvic floor, injuries
of, 815; general considerations
and anatomy, 815; forms of in-
jury, 817; causes, 819; spontane-
ous reparation, 819; results, 820;
palliative treatment, 822; surgical
treatment, primary operation, 823;
secondary operation, 825; flap-
splitting operation, 831; Emmet's
operation, 834, 837; Hegar's
operation, 836; Wood's operation,
838; after treatment, 845; results,
846; mortality, 846.
Peritoneum, pelvic, 43, 46.
Peritonitis, acute pelvic (v.Cellulitis),
402; after laparotomy, 728.
Pessaries, for anterior displacements
of the uterus, 551; for posterior
displacements, 558; for prolapsus
uteri, 574; precautions in the use
of, 553. 560.
Phlegmonous inflammation of the
labia majora, 330.
Physical diagnosis, schema of, 94.
Physical examination, 77, 93, 105;
instruments for, 77-88; table or
chair, 77: vaginal specula, 77;
rectal specula, 83; urethral spec-
ula, 83; cystoscope, 84, 85; uter-
ine sound and probe, 85; tenac-
ula, 86; Nott's depressor, 86;
uterine dilators, 86; curettes, 87;
dressing forceps, 88; Junker's in-
haler, 88.
Placenta, retained, 74.
INDEX.
855
Placental polypi, 620.
Platina, in dysmenorrhea, 275.
Polypi of the uterus, 615; varieties,
615; symptoms, 620; diagnosis,
621; prognosis, 622; treatment,
622; therapeutics, 624.
Polypi, fibrous and blood, 74; ure-
thral, 512.
Polypoidal endometritis, 619.
Positions for examination, 89; dor-
sal recumbent, 89; lateral, 90;
latero abdominal, or Sims's, 91
abdominal, 91; genu-pectoral, 91 ;
erect, 92.
Posterior colporrhaphy, 835.
Pratt's method of vaginal hysterec-
tomy, 654.
Pregnancy, ectopic (v. Ectopic preg-
nancy), 769.
Pregnancy, hystero-neuroses during,
187; removal of fibroids during,
610.
Prevention of conception as a cause
of disease, 26.
Prolapse of the bladder, 569, 820; of
mucous and submucous tissues of
urethra, 507; of the ovary, 764;
of the rectum, 569.
Prolapse of the uterus, 568; etiol-
ogy, 569; pathology, 571; symp-
toms, 571; physical signs, 571;
prognosis, 572; treatment, 572;
hysterectomy for, 575; gastro-
hysterorrhaphy for, 575; pessaries
in, 574.
Prolapse of the vagina, 569, 820.
Pruritus vulvæ, 342; causes, 342;
local applications in, 345: symp-
toms, 344; treatment, 344; thera-
peutics of, 348.
Puberty, hystero-neuroses during,
187.
Pudendal sac, 36; hematocele, 334;
hemorrhage, 334; hernia, 336.
Pulsatilla in dysmenorrhea, 273.
Purulent discharge from genital
canal, 71.
Pyosalpinx, 743.
R.
Rectal specula, 114; touch, 100.
Recto-abdominal examination, 103.
Rectocele, 820.
Recto-vaginal fistula (v. Fistulæ,
recto-vaginal), 537.
Recto-vesical examination, 104.
digital
Rectum, anatomy of, 55;
eversion of, 111; prolapse of, 569.
Reflex functional disturbance and
nervous disorders, 24; symptoms,
how induced, 119.
Regions of the abdomen, 95.
Repositor for replacing inverted
uterus, 581.
Respiration, disorders of in pelvic
diseases, 205.
Retention of menstrual blood from
imperforate hymen, 365; of urine,
516.
Retro-uterine hematocele, 463.
Retroversion and retroflexion, 554;
etiology, 554; pathology, 554;
symptoms, 555; diagnosis, 555;
prognosis, 556; treatment, 557;
pessaries in, 558; Alexander's
operation for, 562; gastro-hys-
terorrhaphy for. 563.
Rupture of the bulbs of the vestibule,
334.
S,
Sacral and coccygeal region, pain
in, 65.
Salivation as a hystero-neurosis, 205.
Salpingitis, acute, 417; chronic (v.
Inflammatory diseases of uterine
appendages), 737.
Salpingo-oophorectomy, 755.
Sanious discharge from
canal, 72.
genital
Sarcoma, of the ovary, 672; of the
uterus, 639.
Scanty menstruation, 230.
Schemata: I. Causes of gynecologi-
cal diseases, 17. II. Development
of the ovum, showing successive
changes following fecundation, 30.
III. Discharges from genital canal,
71. IV. Diagnosis of bodies ex-
pelled from vagina, 73. V. Meth-
ods of physical examination, 94.
VI. Electricity in gynecology, 169.
VII. The hystero-neuroses, 192.
VIII. Dysmenorrhea, 257.
IX.
Vicarious menstruation, 291. X.
Causes of sterility, 306. XI. Dif-
ferential diagnosis of pudendal
abscess, hematocele, hydrocele,
hernia, cysts of the Bartholinian
glands, edema of labia majora
and nymphæ, and neoplasms of
vulva, 341. XII. Comparing in-
856
A TEXT-BOOK OF GYNECOLOGY.
flammation of vagina, uterus and
annexa, and peri-uterine tissues,
428. XIII. Classification of the
cystic and allied diseases of uter-
ine appendages, 663. XIV. Dif-
ferentiating ascites from large
ovarian tumors, 693. XV. Dif-
ferentiating pregnancy from
ovarian tumors, 690. XVI. Clas-
sification of inflammatory diseases
of the uterine appendages, 738.
XVII. Of ectopic gestation, 770.
Schroeder's intra-peritoneal treat-
ment of pedicle, 608.
Scirrhous cancer of cervix, 627.
Seclusion and rest in nervous pros-
tration, 130.
Senile or adhesive vaginitis, 388.
Septicemia after laparotomy, 728.
Sexual hygiene during climaxis, 285.
Sight, immediate, 110; external in-
spection, 110; per speculum (vag-
inal), III; rectal, 114; urethral,
115.
Silk, preparation of, 176.
Silkworm-gut, preparation of, 176.
Simon's operation for fistula, 532;
specula, 82.
Simple vaginitis, 378.
Sims's position, 91; speculum, 81.
Sitting, painful, 68.
Skene's self-retaining catheter, 522.
Skin, reflex disorders of, 212.
Sound, uterine (v. Uterine sound),
85, 105; use of, 105.
Sounds, existing, 115;
115.
roduced,
Spasms, clonic and tonic, 199.
Specific vaginitis, 378.
Specula, vaginal, 78;
Thomas's
Cusco's, 78; Nott's, 79; Brewer's,
79; Goodell's, 80; Wood's, 80;
Sims's, 81; Mundé's, 81; Emmet's,
82; Cleveland's, 82; Simon's, 82;
Ferguson's, 83.
Sponge holder, Wood's, 528.
Sponges, preparation of, 177.
Staffordshire knot, 715.
Stem pessary, 270.
Sterility and
and impotence, 306;
causes, 306; treatment, 314.
Stoltz's operation for cystocele, 844.
Stone in the bladder, 513.
Stricture of the urethra, 506.
Subinvolution (v. Areolar hyper-
plasm), 442;` electricity in, 164.
Superinvolution, electricity in, 164.
Suppressio-mensium, 231.
Sutures, preparation of, 176.
T.
Tait's flap-splitting operation, 831.
Tampons, vaginal, 149; as a carrier
of medicaments, 150; to control
hemorrhage, 150, 248; in uterine
and ovarian displacements, 150;
to retain other bodies in utero, 151;
after operations, 151.
Tapping for diagnosis, 700.
Taxis in inversion of the uterus,
.580.
Temperament and constitutional
bias, 123.
Tenacula, 86.
Thomas's anteversion pessary, 552,
561; retroversion pessary, 558,
561.
Thyroid gland, reflex disturbances
of, 215.
Tight bandaging after parturition as
a cause of disease, 24.
Touch, immediate, 93; palpation,
93; vaginal, 96; rectal, 100; ves-
ical, 100; double, 101; conjoined
manipulation, 101; recto-abdom-
inal, 103; recto-vesical, 104.
Touch, intermediate, 105; uterine
sound, 105; vesical sound, 109.
Trachelorrhaphy, 808; posture for,
808; denudation, 809; instru-
ments, 808; after-treatment, 812;
removal of sutures, 813.
Treatment, general, of gynecological
diseases, 124; indigestion, 124;
constipation, 125; nervous pros-
tration, 129.
Treatment, local, of gynecological
diseases, 138; the vaginal douche,
138; local applications, 142; nar-
cotics, 147; disinfectants, 148;
astringents and styptics, 147;
caustics, 148; vaginal tampon,
149.
Triangular ligament (perineal sep-
tum), 38.
Trillium in fibroids, 625.
Tubal pregnancy, 770.
Tubes, Fallopian, 53.
Tumors, fibroid, 583, 599; ova-
rian, 663.
INDEX.
857
Twisting of pedicle in ovarian
tumors, 679.
Tympanites after laparotomy, 728.
U.
Ulceration of the cervix, 430.
Uretero-vaginal fistulæ, 533; uterine
fistulæ, 533.
Ureters, anatomy of, 55; obstruction
of, 555.
Urethra, anatomy, 55; caruncles of,
511; dilatation of, 509; fissure of,
510; irritable, 513; malformation
of, 506; polypi of, 512; prolapse
of mucous and submucous tissues
+
of, 507; stricture of, 506; vascular
neoplasms of, 511.
Urethral fistulæ, 534; specula, 115.
Urethritis, acute, 492; chronic, 498.
Urethrocele, 509.
Urinary fistulæ, 518.
Urination, painful, 67.
Urine, hysterical, 204; retention of,
516.
Uterine displacements, electricity in,
167.
Uterine hemorrhage, 238; general
considerations, 238; causes, 238;
treatment, 246; therapeutics, 252;
illustrative cases, 254.
Uterine inversion, 576.
Uterine sound, 105; indications,
counter-indications, and dangers,
105; method of employment, 106;
turning, 107; information to be
gained by, 108.
Uterus, absence of, 19, 231.
Uterus, anatomy of, 51; inflamma-
tion of (v. Metritis and endometri-
tis), 399, 429, 437; extreme thin-
ness of, 781; supports of, 543.
Uterus, displacements of, 543;
general considerations, 543; varie-
ties, 543; etiology, 545; symp-
toms, 545.
Uterus, lateral displacements of,
568; prolapse of, 568; inversion
of, 576; fibroid tumors of, 583;
polypi of, 615; carcinoma of,
627; sarcoma of, 639.
V.
Vagina, anatomy of, 54.
Vagina, atresia of, 370; acquired,
370; symptoms, 370; physical
signs, 371; prognosis, 371; treat-
ment, 372.
Vagina, double, 374; inflammation
of, 378.
Vagina, occlusions of, 363; symp-
toms, 363; results, 363.
Vagina, prolapse of, 569, 820.
Vaginal cysts, 375.
Vaginal hysterectomy for cancer,
646; for fibroids, 610; Pratt's
method, 654; membrane, 73;
cysts, 375; specula, 111; touch,
96.
Vaginismus, 352; pathology, 352;
symptoms, 354; treatment, 354;
therapeutics, 357.
Vaginitis, 378; anatomy, 378; varie-
-ties, 378; treatment, 385; thera-
peutics, 386.
Vaginitis, senile or adhesive, 388;
general considerations and his-
tory, 388; diagnosis and prog-
nosis, 393; etiology and pathology,
393; treatment, 395; illustrative
cases, 395.
Vaginitis, simple and specific, 378 ;
causes, 379; course and termina-
tion, 382; differentiation, 74, 381;
pathology, 379; symptoms, 380;
treatment, 385; therapeutics, 386.
Vaginitis, granular or papillary,
384; symptoms, 384; treatment,
385; therapeutics, 386.
Venous angioma, urethral, 511.
Ventro-fixation for retro-displace-
ments, 563.
Versions and flexions of the uterus,
543.
Vesical calculus, 513; parasites, 515;
sound, 109; touch, 100.
Vesico-vaginal fistulæ, closure by
flap-splitting, 533: Simon's opera-
tion for, 532 (v. Fistulæ, urinary,
518); operative treatment of, 523.
Vesicular mole, 73, 75.
Vestibule, 31.
Viburnum op. in dysmenorrhea,
276.
Vicarious menstruation, 291;
schema of, 291; evidence which
justifies a belief in, 295; theories,
296; conclusions, 298; treatment,
298; therapeutics, 299; illustrative
cases, 301.
Vomiting, reflex, 211; after lapar-
otomy, 725.
858
A TEXT-BOOK OF GYNECOLOGY.
Vulva, atresia of, 364; neoplasms of,
338; deformities of, 321; hyperes-
thesia of, 349.
Vulvar region, pain in, 65.
Vulvitis, 327; treatment, 328, 329,
330.
Vulvo-vaginal glands, anatomy of,
34; inflammation of, 331; treat-
ment, 332.
W.
Watery discharge from genital canal,
72.
White's repositor, 581.
Wood's needle for vaginal hysterec-
tomy, 650; operation for lacera-
tion of the perineum, with recto-
cele, 838; speculum, 80; sponge
holder, 528; wire twister, 528.
in
UNIVERSITY OF MICHIGAN
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